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MODERN HAIR RESTORATIONA Complete Hair Loss Guide

For Men And Women2nd edition

byParsa Mohebi, MD

MODERN HAIR RESTORATIONA Complete Hair Loss Guide For Men And Women

2nd edition

Copyright © 2014 by Parsa Mohebi, MD US Hair Restoration

All Rights Reserved.No part of this publication may be reproduced in any form

or by any means, including photocopying, scanning, recording, or otherwise without prior written permission of the copyright holder.

ISBN: 978-0-9910343-1-4

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TABLE OF CONTENTS

INTRODUCTION 9Hair and Image . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Psychological Impacts of Balding . . . . . . . . . . . . . . . . 12A Unique Study on the Psychological Effects of Hair Loss . . . 13Final Thoughts on Hair and Self Image . . . . . . . . . . . . . 16

HAIR LOSS FACTS AND MYTH 17Hair loss facts . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Hair loss myths . . . . . . . . . . . . . . . . . . . . . . . . . . 26

NORMAL HAIR GROWTH CYCLE 37The basic factors a person should know

to better understand hair loss are: . . . . . . . . . . . . . . 37Hair Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . 38Structure of the hair root . . . . . . . . . . . . . . . . . . . . . 38The Normal Growth Cycle of Hair. . . . . . . . . . . . . . . . 38

HAIR LOSS IS HEREDITARY 41Men’s Hair Loss is Multicultural . . . . . . . . . . . . . . . . . 44Causes of Baldness in Men . . . . . . . . . . . . . . . . . . . . 44Treatment of Male Pattern Baldness (MPB) . . . . . . . . . . 46Other Causes of Hair Loss in Men . . . . . . . . . . . . . . . . 48

WOMEN’S HAIR LOSS 51Miniaturization in Women . . . . . . . . . . . . . . . . . . . 52Patterns of Female Hair Loss. . . . . . . . . . . . . . . . . . . 52

HAIR LOSS TREATMENT A Complete Guide to Causes, Prevention and Hair Restoration Techniques

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Patterns in Women’s Hair Loss. . . . . . . . . . . . . . . . . . 53Overall Management of Women Hair Loss . . . . . . . . . . . 54Other Causes of Hair Loss in Women . . . . . . . . . . . . . . 58Medical Treatment of Women Hair Loss . . . . . . . . . . . . 59

HAIR RESTORATION SURGERY 61A Brief History . . . . . . . . . . . . . . . . . . . . . . . . . . 61Hair Restoration Surgery EntersMedical Mainstream . . . . . 62The Innovation of Modern Hair Transplants . . . . . . . . . . 62Micrografting Comes into Vogue. . . . . . . . . . . . . . . . . 63The New Art & Science of Hair Restoration . . . . . . . . . . 65Benefits of Harvesting Natural Follicular Units . . . . . . . . . 67The natural results . . . . . . . . . . . . . . . . . . . . . . . . 68Before and After Hair Transplant Surgery . . . . . . . . . . . 69Is hair transplant surgery for me? . . . . . . . . . . . . . . . . 71Age of hair transplantation. . . . . . . . . . . . . . . . . . . . 71Most men are candidates . . . . . . . . . . . . . . . . . . . . 71Only some women are candidates . . . . . . . . . . . . . . . . 72Medications prior to Hair Transplant . . . . . . . . . . . . . . 72Body Dysmorphic Syndrome . . . . . . . . . . . . . . . . . . 73Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Evaluation before hair transplant . . . . . . . . . . . . . . . . 74How does a hair transplant work . . . . . . . . . . . . . . . . 75Strip Method Hair Transplant . . . . . . . . . . . . . . . . . . 77Critical Factors in Strip Method Procedures . . . . . . . . . . 78Follicular Unit Extraction (FUE) . . . . . . . . . . . . . . . . 79

AFTER HAIR TRANSPLANTATION 87First Few Days After Hair Transplant . . . . . . . . . . . . . . 87Washing Hair After Hair Transplant . . . . . . . . . . . . . . 89Returning to Work After Hair Transplant. . . . . . . . . . . . 89Physical Activities After Hair Transplant . . . . . . . . . . . . 90One Week After Hair Transplant . . . . . . . . . . . . . . . . 90Four Weeks After Procedure . . . . . . . . . . . . . . . . . . . 913 Months After Surgery. . . . . . . . . . . . . . . . . . . . . . 916 Months After Surgery. . . . . . . . . . . . . . . . . . . . . . 92

TABLE OF CONTENTS TOC

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One Year After Surgery . . . . . . . . . . . . . . . . . . . . . . 93After The First Year of Surgery. . . . . . . . . . . . . . . . . . 93Hair Transplant results . . . . . . . . . . . . . . . . . . . . . . 94Hair transplant complications . . . . . . . . . . . . . . . . . . 94Pain and discomfort . . . . . . . . . . . . . . . . . . . . . . . 95Swelling and Inflammation . . . . . . . . . . . . . . . . . . . 95Shock Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96Folliculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Donor scar . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Numbness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

HAIR TRANSPLANT FOR OTHER AREAS 101Eyebrow hair transplant . . . . . . . . . . . . . . . . . . . . .101Causes of eyebrow hair loss. . . . . . . . . . . . . . . . . . . .101Eyebrow Hair Transplant Procedure. . . . . . . . . . . . . . .102Eyelash Hair Transplant . . . . . . . . . . . . . . . . . . . . .104Causes of eyelash loss . . . . . . . . . . . . . . . . . . . . . . .104Eyelash Transplantation Technique . . . . . . . . . . . . . . .105Medical Treatment for eyelash restoration . . . . . . . . . . .105

FACIAL HAIR TRANSPLANT 107Facial to Scalp Hair Transplant . . . . . . . . . . . . . . . . .107Body Hair Lifecycle . . . . . . . . . . . . . . . . . . . . . . . .108Facial Hair Transplants . . . . . . . . . . . . . . . . . . . . .109Body Hair transplant . . . . . . . . . . . . . . . . . . . . . . .110FOX Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

OTHER SCALP SURGERIES 113Facial Feminization Surgery (FFS) . . . . . . . . . . . . . . .113Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . .114Factors that are being taken into account

for a patient’s scalp scar revision are: . . . . . . . . . . . . .114

HAIR RESTORATION MEDICATION 117Expectations from Medical Hair Loss Treatments . . . . . . .1175-alpha-reductace inhibitors . . . . . . . . . . . . . . . . . . .117Propecia (finasteride) . . . . . . . . . . . . . . . . . . . . . .118How Finasteride Works . . . . . . . . . . . . . . . . . . . . .119


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Rogaine (minoxidil) . . . . . . . . . . . . . . . . . . . . . . .119Hair Restoration Medication Side Effects . . . . . . . . . . . .120Finasteride (Propecia) . . . . . . . . . . . . . . . . . . . . . .121Sexual Dysfunction Reported . . . . . . . . . . . . . . . . . .121Hair Loss Gains . . . . . . . . . . . . . . . . . . . . . . . . . .122Long-Term Benefits and Risks.. . . . . . . . . . . . . . . . . .122Other Hair Loss Treatments for Women . . . . . . . . . . . .123Concealers for Hair Loss . . . . . . . . . . . . . . . . . . . . .124Foundations or cover ups. . . . . . . . . . . . . . . . . . . . .125Laser for hair loss . . . . . . . . . . . . . . . . . . . . . . . . .125

ADVANCEMENT IN HAIR RESTORATION TECHNOLOGIES 127

Stereotactic Microscope. . . . . . . . . . . . . . . . . . . . . .127Megasession and Gigasession Hair Transplants. . . . . . . . .128Laxometer . . . . . . . . . . . . . . . . . . . . . . . . . . . .129Motorized FUE Transplants . . . . . . . . . . . . . . . . . . .130FUE Transplant with SAFE System . . . . . . . . . . . . . . .130Robotic hair transplant . . . . . . . . . . . . . . . . . . . . . .131Robotic Hair Transplant Research Continues . . . . . . . . . .132Stem Cell and Hair Multiplication. . . . . . . . . . . . . . . .132Gene Therapy a New Frontier in Hair Restoration . . . . . . .134Growth factors for hair growth. . . . . . . . . . . . . . . . . .135New Medications for Hair Restoration . . . . . . . . . . . . .135

OTHER SCALP PROCEDURES 139Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . .139Scalp Reduction . . . . . . . . . . . . . . . . . . . . . . . . . .140Scalp Micro-Pigmentation (SMP) . . . . . . . . . . . . . . . .141Patient 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143Patient 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143

APPENDIX 143

INDEX 151

Dedicated to my wife and my parents,Without their support my life would not be what it is today.

And to my patients, For their trust and the gift of achievement

they give me every day.I respect them for choosing to transform their lives.

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11INTRODUCTION

HAIR AND IMAGE

“The self-image is the key to human personality and human behavior. Change the self image and you

change the personality and the behavior.”

Maxwell Maltz, (1899-1975)1

Self- image i s important to us and hair

plays a significant role in the way we view ourselves. By the age of fifty over fifty percent of American men will experience

some degree of hair loss that may require medical attention. Although it was thought to be a strictly male disease, women

1 Maltz, Maxwell (1899-1975) was a cosmetic surgeon who developed Psycho-Cybernetics, a system of ideas that can be employed to improve one’s self image and in turn lead a more successful and fulfi lling life.

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actually make up a large number of American hair loss suffer-ers. Hair loss in women is often devastating for their self-image and emotional well-being. As a medical doctor specializing in hair restoration, other physicians and I often hear comments such as:

“I don’t feel good about myself since I started losing my hair.”“I always feel a bit down since my hair started falling out.”“I hate the way I look, some guys are lucky with the bald look, I’m not one of them.”“I look just like my father now; too bad I’m only 28 years old.”

Our self-image is a multi-dimension of complexity in which we see and interpret ourselves. Self-image is the internal unseen thoughts that frame us and how we perceive our physi-cal appearance, and how we value it. Our physical appearance contributes greatly to our self-image. In our quiet internal dialogue most people ponder on how the world sees them and a good portion of our life is spent on working on what we present to the world. Our hair is one of the physical features that reflects how we perceive and feel about ourselves on many levels.

Of course we are more than the sum total of our physical appearance. Still, we live for the most part in a seeing world and what we see provides great sensory awareness. What we see shapes our sense of what we find appealing. This is true of our own self-imaging. Like it or not; historically and today hair plays a significant role in our self- image.

INTRODUCTION CHAPTER 1

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In ancient Egypt, men generally kept their hair short or shaved it off and wealthy Egyptian men wore wigs. The women, kept their hair long, plaited and curled. The wealthy women also wore elaborate wigs. Historians’ document during the 1000 years of heightened Egyptian civilization hair fashion was intricate to social status, the priesthood and the God-like status of the Pharaohs.

Our hair and face are the single most defining physical attributes of our self-image. When a person begins losing hair, his/her self- esteem is often lost with it. Having healthy, shiny, brilliant hair is equated to power, beauty, sexiness and success. This underscores why people’s self- esteem levels drop significantly when hair loss occurs. This longstanding social phenomenon makes hair loss a negatively impacting event for both men and women.

The Internal Revenue Service (IRS) notes that in 2001 the American hair industry generated 25.3 billion dollars2 on haircuts, styling, coloring and more. This simple keratinized protein we call hair is a major sector of our economics and even more so a major factor in a positive personal self-image.

Women are known for spending a lot of time and money grooming, dying, curling, drying, and styling their hair to make it look its best, when they begin to lose their hair, it can be an extremely traumatic experience. Even though in the urban metro sexual era, men do a good share of this, the cosmetic setback is quite intense when a woman is used to

2 2001, Cash Intensive Businesses Audit Techniques Guide - Chapter 10; http://www.irs.gov/businesses/small/article/0,,id=210745,00.html

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having hair and suddenly finds herself losing it. They can have a lot of trouble dealing with the reality of hair loss.

Self- esteem in men is also significantly affected by hair loss. Hair loss causes both men and women to look older; this is what worries many people. The aging factor is a large part of the reason people lose their self- esteem when they lose their hair. Emotional problems that come from hair loss can interfere with every aspect of someone’s life, including love, career, and relationships. The stress that comes with hair loss only worsens the situation.

If you experience hair loss and it is affecting your life, the best thing to do is determine the cause of the hair loss and visit a qualified physician for a consultation to discuss hair restoration treatment options.

PSYCHOLOGICAL IMPACTS OF BALDINGBalding and its psychological impacts has been the subject of many studies in the past. The relationship between hair loss and stress is clear to all clinicians who practice in this field. Negative psycho-social impacts of hair loss in male patterned baldness and in women with hair thinning or balding have also been seen. Many hair transplant surgeons observe the negative effects of hair loss on self- esteem and self-image in their patients.

Reported effects from some male patients include: ● Detrimental impact on their sex life ● Aff ected career choices in men ● Inability to stay competitive at the work place


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● Increased anxiety levels among younger men ● A higher rate of depression in men with male

patterned baldness

There has been solid evidences and published literature on the psychological impacts of hair loss in both men and women. However, the corrective effect of medical and surgi-cal hair restoration has not been studied until recently. After observing the drastic changes in patient’s behavior and the high level of patient satisfaction in those who have had a hair transplant, we were motivated to look into the psychological impact of hair restoration on different aspects of a patient’s life.

A UNIQUE STUDY ON THE PSYCHOLOGICAL EFFECTS OF HAIR LOSS

In 2008, Dr. William Rassman and I conducted a unique study3 to quantify the psycho-social impact of hair loss in men with typical male patterned baldness. We came up with a series of criteria based on previous studies and our clinical observations that could have been modified by having a hair restoration procedure. We utilized indices that were previously studied comparing bald and non-bald men on different psychological variables.

Initially, a pilot study was performed in which patients were asked about different aspects of their lives during their post op visits. Patients received open ended questionnaires

3 Psychology of hair transplant, Hair Transplant Forum International, the Journal of International Society of Hair Restoration Surgery, cover article, Volume 18, Number 2, March/April 2008.

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eliciting responses as to their psychological state after their hair restoration procedure was completed. Based on the pilot study, we focused on eight major criteria, reported and docu-mented as variables associated with hair loss in the literature.

A subset of patients from our pilot study was collected. Their questio nnaires included questions on the general level of happiness, energy level, feeling of youthfulness, anxiety levels, self confidence, and outlook on their future and even impact on their career and sex life. We chose patients who had their first hair transplant surgery between one to three years prior to the time of the study. This meant the patients had clearly experienced the final result of their hair restoration procedure. This study was limited to men with male patterned baldness. It was anticipated that patients whose surgeries were less than three years back would have strong memory recall. The patients chosen exclusively had received follicular unit transplants that reflected the best practice standard of care in hair restoration.

Two Hundred questionnaires were sent to this group of hair transplant recipients. It also included a brief description on the nature of the scientific study. Patients were permitted to respond anonymously and their parti cipation was voluntary. We found out that the patients had significant improvements in all eight criteria regardless of their stage of baldness and their ages. In the graph below Figure 1 shows that in 18% of the respondent group, there was a greater sense of well being in their overall happiness, energy levels, careers, sex life and youthfulness. Respondents also felt a sense of improved anxiety,


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self confidence and future outlook on life. Our study confirms the significance of hair to people’s self-image and esteem.

Figure 1: Illustrates the improvement of psycho-social variables quantifi ed in the Mohebi/Rassman Study of hair

restoration patients in 2008.

Hair restoration surgery affects many aspects of a patient’s life. Natural looking results from today’s hair transplant sur-geries can potentially reverse many psycho-social problems as-sociated with hair loss. The positive impact of hair restoration is more visible among patients who suffer from those effects the most. In early stages of hair loss, patients may have more awareness of their condition and they might be more affected than those in the later stages of hair loss.

According to the study, patients who experienced hair loss at an early age and also had an active social life were

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more prone to the negative effects of balding such as anxiety. Therefore we can assume that hair loss can have a negative impact on a patient’s future outlook, which seems to reverse after receiving a hair restoration procedure.

Although the response rate in our study was not one hundred percent, it supported what hair restoration physi-cians report from observation and from anecdotal evidence of patients. Efforts are being made to repeat the study in the future, in larger scales. Most importantly it is clear with the advancements in hair restoration, providing natural results for men and women who suffer from hair loss is crucial.

FINAL THOUGHTS ON HAIR AND SELF IMAGE

If you are experiencing hair loss but it does not negatively impact your life then hair restoration surgery is most likely something you would not choose to do. However, for most men and women who are suffering from hair loss hair restora-tion makes significant improvement in many aspects of their psycho-social lives including but not limited to their overall happiness, self esteem, future outlook, sex life and career.

Since you are reading this book, it is likely that either you or a loved one might benefit from a professional consultation and evaluation with a hair restoration doctor. Enjoy reading this book as it will answer many of your questions. Most of all I wish you the best in health and life.

22HAIR LOSS FACTS AND MYTH

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Hair loss is evident throughout the records of human history. As far back as ancient Egypt there is anthro-pological evidence that wigs and hair augmentation

of some type was a cultural norm. Though people now live longer thanks to general health improvement, hair loss has yet to be eradicated and still has strong cultural ramifications.

The strong emphasis placed on hair in society un-derscores sometimes fosters desperateness in people suffer-ing from hair loss. This anxi-ety causes many people to try pretty much anything and al-most everything that is claimed to be effective. This reason has led to exploitation of persons with baldness. Unfortunately, the proliferation of myth over

fact causes confusion for people who genuinely seek remedy for hair loss. In this chapter, we will present some facts and


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myths regarding hair loss and hair restoration. If you smile or have a chuckle reading here it’s okay. It’s amazing how some myths have been perpetuated.

HAIR LOSS FACTSMost doctors will tell you to eat a balanced healthy diet with whole foods from the basic food groups. A healthy dietary intake benefits every aspect of our body. For centuries healthy hair and skin have been perceived as an indicator of inner health. This is true to a good extent. A well balanced diet contributes to feeling and looking well. What a surprise! But let’s get to some basic hair loss facts.

1. Our hair is made of a proteinHair and nails are actually a variation of skin. Th ey are all forms of a keratinized protein. Hair grows all over the human body. Th e exceptions are the palms of the hands, soles of the feet, and lips.

2. Only hair root mattersA hair consists of a hair shaft (the part we see), a root below the skin, and a follicle from which the hair roots grow. It is the damage to the hair follicle that eventually leads to hair loss, which is considered a medical condition. Th is should not be confused with the normal shedding of hair. It is normal to shed hair;Losing 50 to 100 hairs is considered normal. Occasionally and under special circumstances this number may go up to 200 hairs per day. Any amount of hair over that might mean that something is wrong. Th ere is no need to count those hairs from

HAIR LOSS FACTS AND MYTH CHAPTER 2

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your brush or comb. Hair loss that demands medical attention is most oft en perceptibly noticeable.

3. Color of hairTh e hair color pigment or melanin is produced at the hair bulb, which is located at the lower end of the follicle. Th is is why no hair color is truly permanent. Your hair color is programmed genetically over the course of your lifetime. Some environmental factors such as the sun or chlorine can alter hair color but not the color of the hair growing from the follicle.

4. Hair loss and stressTh e hair shaft falling out or hair shedding could be directly connected to stress, sometimes that stress is caused by excessive work, family problems or major illness or surgeries. When stress is eliminated or relieved hair will usually return to its normal growth pattern. However, if you are genetically prone to baldness, stress may hasten something that is going to happen anyway and it might not reversible. It is best to have a medical evaluation when a perceptible level of hair loss occurs.

5. Hair loss because of hormonal imbalancesHair loss can be caused by hormonal problems, and correcting the hormone imbalance may stop the hair loss. Hormonal changes are oft en related to hair loss. Th e important thing is to learn the route of the hormonal change. Pregnancy and postpartum periods are obvious examples of such conditions that aff ect hair growth and hair loss. Alteration of both


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male and female sex hormones may be a cause of hair loss conditions. Other hormonal problems can be caused by an overactive or underactive thyroid gland.

6. Hair loss aft er giving birthMany women experience hair loss in the fi rst few months of giving birth. During pregnancy high levels of progesterone usually causes the body to keep and grow the hair that was supposed to fall off naturally. It is therefore considered normal, that when the progesterone levels drop to the pre-pregnancy levels, that supporting eff ects of those hormones are gone and hair starts to fall out. Th e natural hair loss and growth cycle should resume in a few months.

7. Medications can cause hair lossHair loss can be caused by the use of certain medicines or treatments. Blood thinners (anticoagulants), gout medicines, chemotherapy (used for cancer treatment), Vitamin A (in large amounts) as well as some birth control pills and antidepressants have hair loss indicated as a possible side eff ect. Th ere are many more medications that have hair loss as one of the rare side eff ects, but don’t worry too much if you see hair loss listed in the problems that may happen aft er taking any medications, just discuss it with your doctor to see how much it is relevant to your current condition. Hair loss should usually stop when you stop taking the medicines. Your doctor may suggest you a change of medicines or treatment that won’t cause you the hair loss.


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8. Fungus and hair lossHair loss can be caused by fungal infections of the scalp. Th ese conditions can be treated with anti-fungal medicines. A physician should be seen as soon as possible.

9. My immune system causing my hair lossHair loss can be caused by an autoimmune disease known as alopecia areata (AA). AA is caused by an overreaction of one’s own immune system. It initially appears as small round and coin shaped bald patches on the scalp which can get bigger in some cases. Th e hair oft en grows back naturally within six months to a year in most cases but those patients might experience that kind of alopecia again.

10. Hair loss can be a result of poor nutrition. Anorexic and bulimic people experience hair loss because their body gets the necessary nutrients needed for many bodily functions. Hair loss that leads to typical patterned baldness is most oft en not from nutrition but from a signifi cant stressor or genetics. Th is is discussed in detail in upcoming chapters.

11. Causes of typical men hair lossA very frequent kind of hair loss ( alopecia) commonly called male- pattern-baldness or in medical terms, androgenic alopecia. Th is is caused by genetic factors but can be accelerated by a combination of many other factors including stress, medications and hormonal changes.


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12. Good diet cannot stop hair lossEating a healthy balanced diet is good for your health and general well-being. Th is is true in the sense that a good dietary intake provides the body with the nutrients it needs to function properly. However, your patterned hair loss is not associated with your nutrition; there is no diet that is known to stop patterned hair loss. Balding will eventually occur despite having a balanced diet.

13. Shampoo and hair lossSome doctors advise their patients to use baby shampoo and not to wash your hair more than once a day. Th e thought here is to use gentle hair care products. Some hair care cosmetics are harsh and damage your hair despite their claims to be helping your hair loss. However, this is not the main cause of patterned hair loss. Your genetics most oft en are.

14. Pulling hair can cause permanent hair lossPuling hair on a regular basis as in people who do tight braids or the ones using thigh turbines can cause a special form of hair loss, called traction alopecia. You should avoid anything that pulls your hair continuously for prolonged periods of time.

15. Hair loss is a diseaseHair loss is a common disease but because it is so common in men we generally do not take it seriously. If you experience unexplained hair loss or you have a genetic factor that might cause you to lose your hair, seeing a medical doctor is the best thing to do to


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determine the cause of your hair loss. It is advisable to consult a doctor before starting any of over the counter medications that might be available without prescription. Th is will help the doctor get a better understanding of your hair condition.

16. Styling can damage hairStyling hair with rollers and irons, vigorously brushing, pulling or tight braiding, as mentioned before, can cause damage to hair shaft s or even hair follicles. Damaging the hair shaft should however; not be mistaken with typical male or female hair loss.

17. You can avoid chemical damage to your hairYou should always test chemical hair processes before applying them to your entire hair. When using products such as relaxers, permanents, or hair color, you should try fi rst on a small section on the back on both skin and hair to check for allergies and hair loss or damage. Aft er a successful test wait a few days and then have the process on your entire hair and scalp. It is always better to have them done by a trained and licensed professional.

18. Steroids can cause hair lossSome medications are known to have the side eff ect of hair loss. Anabolic steroids are well known for this. Th ough they might not cause hair loss for someone who isn’t genetically predisposed to hair loss, this group of steroids can exacerbate balding tendencies in someone who is genetically susceptible to male pattern baldness.


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19. Genes are the main cause of hair lossIt is important to note that hereditary hair loss is responsible for almost all patterned hair losses and it is not aff ected by nutrition to any perceptible level. If hair loss is due to nutritional/dietary defi ciency then improving nutrition will most likely cause the hair loss to abate.

20. Hair loss may be related to depressionMany people normally experience depression when they start losing hair. Scientifi c research shows us that people with hair loss have higher rates of depression. Many people with situational baldness or female/ male pattern baldness suff er in private. If this is you, then you should not despair because the condition can be improved by hair restoration. For more on this you can review our article, “Psychology of Hair Transplant”

21. Mineral defi ciency can cause hair lossAcute defi ciency of some minerals may cause hair loss or thinning, dermatitis, and slow hair growth. Zinc is one of the minerals that may cause hair loss in its severe form. Both poor appetite and poor digestion are also experienced by adults with a zinc defi ciency. Iron defi ciency can also cause hair loss in a diff use form. Iron defi ciency can also accelerate the rate of hair loss if you’re predisposed to other types of hair loss such as patterned alopecia.


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22. Stress can cause hair lossStress is directly related to hair loss and is one of the primary causes of thinning hair. Hair loss induced by stress can be caused by physical or emotional stress. Aft er severe stressors, such as surgery, trauma or illness hair loss can occur. Th is type of hair loss is referred to telogen effl uvium or TE. Telogen Effl uvium is when a large number of hair follicles decide to go to resting phase at the same time. TE oft en takes as long as four to six months to reverse itself.

23. Hair loss can cause social anxietyWe mentioned above, stress could be related to hair loss and may accelerate it. Some studies show that hair loss can cause anxiety especially in young adults who suff er from patterned hair loss. Th e way we look is very important in social life of young adults and losing hair in those socially active years could be devastating. Our studies show that hair restorations have been able to improve anxiety in young adults.

24. Hair loss can aff ect sexOur study, that is published in hair transplant forum international, reveals that most people who had a hair restoration reported signifi cant improvement in their overall sex life.4

4 Psychology of hair transplant, Hair Transplant Forum International, the Journal of International Society of Hair Restoration Surgery, cover article, Volume 18, Number 2, March/April 2008


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HAIR LOSS MYTHSHair loss is a very common occurrence throughout the world; it spares no social strata, culture or ethnicity. Fortunately, the latest technologies in hair restoration provide solutions that help hair loss sufferers to regain confidence in their self-image. The root causes of hair loss are varied, the most common being male patterned hair loss and female patterned hair loss.

Let’s take a moment and clear up some of the common myths or misconceptions that we hear every day in our hair restoration centers. Now, this is an interactive chapter; you might have some fun noting in pencil which ones you have heard before, which ones you think are true or false! But by the time you finish reading you will definitely know what the myths are.

May we have a drum roll please, presenting …

The Greatest Hair Loss Myths 1. Too much shampooing contributes to hair loss

A clean healthy scalp is good. It is okay to have a little ‘OCD’ about real clean hair. Th is will not make your hair fall out. Shampooing can be based on the type of work environment you are in and your body own secretions of oils.

2. Hats and wigs cause hair lossBold face untruth. Th is is based on the fl awed reasoning that poor oxygenation is at the root cause of hair loss. Th is is simply not true. Hair follicles need oxygen but they get it from blood circulation and not from skin surface.


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3. Shaving your infant’s head will make hair grow thickerYou really have to wonder how this one came about. In many cultures it is traditional to shave the baby’s head in ceremonial ritual. Many babies are born with little and very uneven hair. When you shave you lose the tapering end of hair and you can see the tip of new hair is coarser. Hair cutting, shaving at any age does not promote hair growth.

4. Coloring and other hair cosmetic treatments are causing permanent hair lossTh is is simply not true. Hair coloring only aff ects the hair shaft s that are dead parts of hair and hair follicles are not aff ected in any way by coloring or chemically processing hair. Chemical treatments combined with long term tight hairstyles such as braiding or plating can lead to traction alopecia; however it does not cause pattern baldness.

5. Women are expected to develop thicker hairWomen in general seem to grow hair longer than men. However, color and thickness of hair is hereditary and varies from person to person.

6. We lose hair because of lack of blood circulationHair follicles obtain their oxygen and nutrients from blood circulation, but typical patterned hair loss among men and women has nothing to do with circulatory problems. If the balding area of scalp had less blood supply, hair transplant could not bring hair back to the balding area, or if it did transplanted


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hair would be prone to baldness too. We know that transplanted hair follows the pattern of hair growth of the donor area and is not aff ected by the genetic pattern of baldness.

7. Standing on one’s head will stimulate hair growthAs mentioned above, patterned baldness is not secondary to circulation problems. If this were true the vast amount of middle age men with hair loss would lose their bellies, buff up their torsos and walk to work on their arms. If you start seeing this in your locale then there has been a great scientifi c revelation. However this is highly unlikely.

8. Dandruff causes permanent hair lossExcessively dry scalp can lead to build up of epithelial cells on the scalp that fl ake off but have nothing to do with hair loss. Nevertheless severe dandruff may require the evaluation of a dermatologist. Th e cause of hair loss is not topical or epidermal.

9. Th ere are cosmetic products that will grow hair fasterWell, everyone losing hair has fallen for this one most likely and a lot of folks have made a lot of money and still do. Th is is simply a fallacy. If it was true the millions and millions of hair loss suff ers would not be bald! Th ere are some medically approved solutions such as minoxidil that can slow down the process of balding. Some cosmetics may have these as their active ingredients. However, if you want to utilize these medications it is better to use them pure and


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not as an addition to a shampoo or other cosmetic product.

10. Permanent hair loss is the result of stressHair loss can be accelerated by stress. However, in most cases when the stress is relieved hair returns to its normal growth cycle in six to twelve months.

11. Typical male hair loss starts aft er twentiesUnfortunately, the hormonal changes at puberty can aff ect hair loss in some adolescent males and in rare circumstances females. It may not be completely apparent, but microscopic evaluation or a miniaturization study can reveal the early signs of patterned hair loss even in mid to late teens.

12. Hair loss aff ects intellectuals moreRemember all those men walking to work on their arms earlier they took a special medication called ‘Low IQ’…nope, this is a myth. You can have a prolifi c head of hair and not the intellect to match…imagine that!

13. Androgenic Alopecia can be curedOnly hair restoration and some medications are the only proven method of alleviating the eff ects of androgenic alopecia. As of now there is not a cure for male patterned baldness.

14. Wearing a tight baseball cap too oft en will make you baldTh is is the poor circulation concept in hat form. Total Myth! However there is a condition called turbine alopecia that is seen mostly in Indians who wear very


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tight turbines for most of their lives. Th at is a type of traction alopecia that will be discussed later. I have never seen it happening with baseball caps!

15. Brushing helps you grow hair Th e idea of brushing the hair 100 times a day to stimulate the scalp circulation is a fantasy. In fact, if you brush your hair too much, you may end up traumatizing your hair shaft s. Th is myth stems from the thought that hair loss was due to poor circulation and that brushing or massaging would improve blood fl ow and nutrition to the follicles. Th e truth is, bald or not, there’s no major diff erence in scalp circulation..

16. Styling causes hair lossTh ere is some truth and some fi ction when it comes to hairstyling and hair loss. It is true that certain hairstyles, such as cornrows or tight ponytails for long periods, can cause hair loss. Th ese styles put undue tension on the hair. As for hair sprays, perm solutions, or coloring resulting in hair loss there’s no truth to that idea. Th ese applications may cause some damage to the hair strands. But the all-important follicles, located under the skin, stay safe.

17. More frequent haircuts will make your hair grow fasterTh at is wishful thinking. Everyone’s hair growth and length depends on their own unique hair cycle, which is primarily heredity. Th e longer your hair growths phase the longer your hair growth. Your hair follicles have no way of knowing how long your hair shaft is.


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18. Blow drying your hair will cause your hair to thin outTh ere is no evidence that hair dryers cause thinning hair. Over drying can lead to damage that renders your hair brittle and more breakable. Hold the hair dryer at a distance from your scalp well enough to dry it but not to scorch it.

19. Vitamins will make your hair growIf you are losing hair because of a lack of vitamins or minerals in your diet, why wouldn’t the back and sides of your head be aff ected? In actuality, vitamin defi ciency usually results in an even distribution of hair loss all over the head, i.e. thinning of the hair. It does not hurt to take vitamins on a regular basis for your overall health especially in certain conditions that are recommended by doctors. Your follicles width and amount are based on heredity. So claims of hair growing miracle drugs or natural hair loss treatments are untrue to that extent. Improved nutrition helps the whole body within its genetic predisposition.

20. Steroids can help your hair grow better Anabolic steroids can cause hair loss. Research has proven that anabolic steroids raise the levels of baldness-inducing male hormones. For those who are genetically prone to hair loss, this can speed up the loss in as little as three to six months. While this loss may be reversed, it can be permanent in some cases.

21. Sexual activity increases hair growthWishful thinking folks... there is no truth to the idea that the more sex you have, the less hair you will lose!


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Or that the chemicals released during sex can aff ect hair loss. Th e opposite is not true either. Science has yet to uncover any proof to these fantasies. But that doesn’t mean you shouldn’t keep conducting your own clinical trials (wink.)

22. My father has a great head of hair so I have no worriesMany men believe that if their father has a full head of hair, they will keep a good head of hair. Nonetheless, hair loss or hair growth is set by a genetic combination determined by both sides of your family. Of course, if your family tree is fi lled with balding scalps, you do have a better chance of losing hair.

23. Baldness is passed down from your mother’s side Hereditary hair loss, or androgenic alopecia, is considered the main cause of hair loss in women and in men. It accounts for 95% of male hair loss. Long considered a trait inherited from our mother’s side, genetic hair loss actually results from a combination of the genes from our mother’s and our father’s sides. Although you cannot entirely predict the future of your hairline based on your mother’s or your father’s scalp, you can get a good indicator from comparing the collective hairlines of your parents, grandparents, aunts and uncles.

24. Tightness of scalp can be the cause of hair lossTh is is not true. During pre-op evaluation, we examine peoples scalp laxity with a device called


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Laxometer. We have seen a range of very loose to very tight scalps among balding people and there has not been a signifi cant relationship between scalp tightness and hair loss. Th erefore you probably can guess that scalp massage cannot help that recessing hair line of yours either but it can lead to some enjoyable life moments!

25. Stress is the main cause of hair loss in menWhile none of these symptoms are known to create permanent hair loss, they can all create signifi cant temporary hair loss in men and women. When it comes to vitamin or nutritional defi ciency and intense stress, the resulting temporary hair loss is called telogen effl uvium. Th is hair loss happens when the body experiences a shock, either from psychological stress, sudden excessive weight loss, metabolic changes, vitamin defi ciencies or a virus. When one of these situations occurs, the hair is forced into the resting stage of the hair growth cycle prematurely, resulting in sudden drastic hair loss. However, it is not the typical hair loss men experience as male patterned baldness.

26. Using a night cap can prevent hair lossSome people have maintained that keeping the scalp covered during night or day can increase blood fl ow of the scalp and thus boost hair growth. However, because alopecia is primarily caused by the presence of DHT and genetic predisposition rather than blood fl ow using night hats won’t have any eff ect on your hair.


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27. Regular shaving make your hair regenerate fasterGetting frequent haircuts or shaving head might be considered a good way to keep existing hair healthy by removing damaged, split end., However, haircuts have no eff ect on your hair’s growth rate or thickness overall. It is simply the duration of a person’s unique hair growth phase.

28. Smoking causes hair lossAlthough this myth has been discounted in the past as being an invalidated assumption, a thirty year study by the research group, the British Medical Journal (BMJ)5 have found suffi cient evidence to claim there might be a link between smoking and hair loss. It’s still uncertain whether the connection is due to the eff ects of tobacco toxins, or the fact that smoking accelerates aging and other health problems. So although this is not quite a myth, we wanted to get your attention about another hazard of smoking!

29. Hair loss cannot be treatedIn the past, there were no eff ective treatments in sight for hair loss and hair thinning patients; the only solution was to cover up hair loss with hats and artifi cial hairpieces. Fortunately, there are many eff ective hair loss medications and treatments in today’s market that can either prevent future hair loss, or replenish balding hairlines. Th e most popular hair loss medications include Rogaine® ( Minoxidil) and Propecia® ( Finasteride). Rogaine acts as a hair

5 BMJ 1996; 313 doi: 10.1136/bmj.313.7072.1616 (Published 21 December 1996)


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growth stimulator while Propecia prevents hair loss by inhibiting DHT production and activity. Th ere is more on hair loss medications in that section in this book. Th ose medications are mostly to prevent or slow down hair loss, but hair transplantation can restore ones balding head by relocating hair from areas with permanent hair growth to balding portions permanently. Today this is absolutely a myth.

30. I have to wait till I am completely bald before I can have a hair transplantIn the past, hair transplant surgeons did not perform a hair transplant before the patients in their mid-twenties. Some surgeons refused to perform hair restoration before a person lost all of his or her hair. Today we know that hair restoration could be done at any age as long as we can determine the fi nal pattern of hair loss with microscopic evaluation and through family history of balding. Hair transplant surgeons do not have to wait for you to go completely bald before performing a hair transplant. In fact we would like to perform a hair transplant before anyone knows you are balding. Medical treatments could be added to hair restoration to preserve your native hair in balding areas. Th e combination of surgery and medical treatments of hair loss can change what was known to be your hair destiny.

Well, there you have it some serious hair restoration truth separating facts and myths. These are some of the common myths heard by hair loss specialists on a daily basis. It is


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recommended that you first have your hair loss diagnosed by a competent hair loss expert. Hair transplant surgeons are medical doctors who see hair loss patients regularly. Once you have received a thorough evaluation and consult you will have a better understanding of exactly which treatment options are available and what may be best for you.

3NORMAL HAIR GROWTH CYCLE

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The basic factors a person should know to better under-stand hair loss are:

● Understanding hair structure ● Understanding the hair growth cycle

HAIR STRUCTUREHair is composed of durable resistant structural protein called keratin. Keratin is the same kind of protein that makes up the nails and the epidermis (outer layer of skin.)

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There are three layers of each hair strand. These layers are: ● Th e Medulla: is the core innermost layer ● Th e Cortex: provides color, strength, and texture ● Th e Cuticle: is the thin and colorless; it is the outer

most layer of hair

STRUCTURE OF THE HAIR ROOTThe hair root lies beneath the skin’s surface and is contained in a hair follicle. The dermal papilla is made up of the base of the hair follicle. The bloodstream feeds the dermal papilla, which carries nourishment to produce new hair. The importance of the dermal papilla is magnified as the receptors for male hormones and androgens are within it. It is androgens that regulate hair growth. It is the androgen - dihydrotestosterone ( DHT) that causes the hair follicle to get progressively smaller and the hairs to become finer in individuals who are geneti-cally predisposed to this type of hair loss.

THE NORMAL GROWTH CYCLE OF HAIRThere are three phases of the hair growth cycle:

Normal Hair Growth Cycle

Phase Function Duration

Anagen Growth 2 - 8 years

Catagen Degradation 2 - 4 weeks

Telogen Resting 2 - 4 months

On average 50-100 telogen hairs (resting phase) are shed every day. Th is is normal everyday hair loss found in our comb or the shower. Th ese hairs regrow in the anagen phase.

NORMAL HAIR GROWTH CYCLE CHAPTER 3

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About ten percent of the follicles are in the resting phase ( telogen) in a given period of time. Medically this is referred

to as shedding; it is just normal hair loss.

There are various factors that affect the normal hair growth cycle and cause temporary or permanent hair loss ( alopecia) including; medication, radiation, chemotherapy, exposure to chemicals, hormonal and nutritional factors, thyroid disease, generalized or local skin disease and stress.

Androgens are the most important factor in hair growth. These hormones are testosterone and dihydrotestosterone ( DHT). It is the presence of androgens that fosters the beard and the growth of auxiliary hair underarms and pubic hair. Scalp hair is not androgen dependent; but androgens are the underlying cause that initiates the genetic predisposition of male and female pattern hair loss otherwise referred to as Male Pattern Baldness ( MPB) and Female Pattern Baldness ( FPB). Medical science advances in the recent years have elevated medical hair restoration and hair transplant surgery

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as a preferable option for men and women; hair restoration is a highly successful method for treating MPB and FPB.

44HAIR LOSS IS HEREDITARY

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We are the sum of our genes in many ways. Even though we may favor one parent over the other, as we become more acquainted with different family

members on both sides, we start to find common traits with various members from our families. Though certainly one parental side may be more dominant over the other, our hair and the loss thereof, to a significant point, is also hereditary.

Perhaps you know someone in their teens or early twen-ties who has started to experience thinning hair. The odds are the culprit is hidden in that complex of genetic code we call our ‘family tree.’ Nearly ninety- five percent of men and seventy percent of women with thinning hair can attribute it to a hereditary condition called Androgenic Alopecia ( male or female patterned baldness). In layman terms it is referred to as male patterned baldness ( MPB) in men and female pattern baldness ( FPB) in women.

Hair loss is an equal opportunity culprit. Androgenic Alopecia affects all ethnicities and can be inherited from either the paternal or maternal side of the family. There are a

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numerous genetic factors that determine baldness; it may or may not skip generations.

Hereditary hair loss is characterized by: ● a progressive miniaturization of hair follicles ● a shortening of the hair’s growth cycle

As the growth phase shortens, the hair becomes thinner and shorter until, eventually, there is no growth at all.

Male and Female Patterned Baldness

The most common type of hair loss in men and women, or pattern baldness, is a condition as a result of some combination of genetics, hormonal changes, and the aging process. Among all, genetics is the most important factor contributing to one’s hair loss. Hereditary- pattern is also known as patterned baldness. Patterned baldness is most often referred to as male patterned baldness ( MPB) in men and female pattern baldness

HAIR LOSS IS HEREDITARY CHAPTER 4

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( FPB) in typical woman hair loss. The incidence of MPB6 far exceeds that of FPB.7

Medical science, developments and advancements in hair restoration have made male- pattern and female- pattern androgenic alopecia a treatable condition with very successful results. Improved self-image and esteem that men and women gain through successful hair restoration is beneficially life changing.

MPB and FPB are so common that today’s medical profes-sionals have been paying more attention leading to the boom in advancements in hair transplantation. These surgical and medical hair loss treatments have high rates of success.

Hereditary hair loss is gradual, but the sooner treatment is started, the better the chances of results that will please the patient throughout the course of their life. Checking your family tree to see if you have a possible genetic predisposition to hair loss might help you recognize the symptoms early enough to slow the progression with today’s FDA approved medications.

The advances in research have helped medical profes-sionals to better understand the cause of this most common type of hair loss and balding genes. Under the influence of a form of the male hormone, the normal cycle of hair growth changes in hair follicles that are genetically prone to baldness,

6 Male Pattern Baldness’, March 01 2010, WebMD:http://www.webmd.com/skin-problems-and- treatments/hair-loss/hair-loss-introduction-mens7 “Women and Hair Loss: Th e Causes”. June 06 2010, WebMD: http://www.webmd.com/skin-problems-and- treatments/hair-loss/features/women-hair-loss-causes

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resulting in shorter, thinner or “ miniaturized” hair. Later in this book we will learn more about this common hereditary challenge and hair miniaturization process.

MEN’S HAIR LOSS IS MULTICULTURALHair loss affects up to 60% of the male population in every eth-nicity; this common worldwide phenomenon is also referred to as male patterned baldness ( MPB.) The past decade has brought forth advancements in medical science and medical technology making resolving MPB a viable option for many men through hair restoration.

Modern hair restoration through hair transplantation provides as a natural, proven and permanent solution for men. Hair transplants are now one of the most common cosmetic procedures elected by men today.

CAUSES OF BALDNESS IN MEN

The Most Common Cause of Baldness in Men Hormonal and genetic factors both play a role, but the exact root mechanism for baldness in men is still being researched by medical science. This will affect more men by each decade of their life. Male Pattern Baldness affects 20% of men in their twenties, 30% of men in their thirties, 40% of men in their forties and so forth. MPB Hair loss can begin even in the latter stages of puberty. The Hamilton-Norwood scale is used for the classification of male pattern baldness and is based on the progress and severity of hair loss. Currently, several treatment options are available. Besides hair transplantation, there are


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two medications that have been FDA approved for use in the United States. Patients who benefit the most from effects of medications on slowing the baldness process are still in the initial stages of baldness.

Hair loss classifi cations for men with MPB

Research has proven that the prime culprit in MPB is Dihydrotesto sterone ( DHT) a powerful sex hormone is known to adversely affect hair follicles in the crown, top and temples of the scalp. DHT is clinically verified as the trigger for male pattern baldness. In addition, researchers noted that men with MPB also have elevated levels of the enzyme 5-alpha-reductase.

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The act of genes, hormones and time makes the sus-ceptible hair follicles in those regions of the scalp produce a shorter and finer hair over time. When no medical interven-tion takes place these follicles will eventually cease to produce hair shafts at all. This process is called miniaturization. The progress of this miniaturization causes disappearance of cer-tain hair shafts and shrinkage of the others. In this process the scalp hair becomes very fine and short, which is also known as miniaturized hair.

TREATMENT OF MALE PATTERN BALDNESS ( MPB)

The centuries old medical treatment for baldness in men is a longstanding historical challenge. Finally, for the first time in history, FDA approved medications are having measurable effects on pattern hair loss in men. These results vary from person to person but are successful enough to garner FDA approval.

SOME OF THE DRUGS INCLUDE:

MinoxidilIt is one of two Food and Drug Administration ( FDA) and first approved medications; it comes in topical form. Minoxidil is available in 2% and 5% solutions. It needs to be applied to the balding areas of the scalp and its effectiveness is usually not noticeable for several months after initiation of treat-ment. Positive results of the medication are not permanent and in most cases the patient will still experience hair loss after the medication has been discontinued. Hair transplant


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surgeons may recommend use of Minoxidil treatment along with hair transplantation as a compliment for successful hair restoration.

Finasteride ( Propecia)This is the only available oral medication for male pattern baldness. It is available for hair loss treatment in one milligram pills and one pill should be taken every day. In the absence of a hair transplant withdrawal from finasteride usually leads to reversal of hair loss within 12 months.

Hair TransplantHair transplant is the natural, proven and permanent treat-ment for baldness in men. Formerly, surgical treatments such as plug grafts, scalp flaps and scalp reductions were used with less than desirable results for patients. The advancement and discovery of Follicular Unit Transplant ( FUT) revolution-ized hair restoration treatment of hair loss for both men and women.

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OTHER CAUSES OF HAIR LOSS IN MEN Alopecia Areata Alopecia areata is an auto-immune disease that affects hair follicles anywhere in the body, appearing as round patches without hair. Alopecia areata affects both men and women and could be seen almost anywhere on the skin.”

Anagen Effl uviumThis refers to sudden hair loss due to the effect of chemicals or radiations such as hair loss following chemotherapy, radiation therapy or toxins. This condition is different from Telogen effluvium, where hair enters the resting phase. In this condi-tion, hair loss begins 1-3 weeks following exposure to the inducing factor. Some types of anagen effluvium such as hair loss after chemotherapy could be temporary and hair growth is back to normal once treatment is finished. The texture of hair could be somehow different after re-growth in some cases.

Trichotillomania Trichotillomania is a hair loss condition, in which patient’s continuously pull hair causing hair loss in some areas. This condition is usually an outgrowth of an underlying emotional and psychological disorder such as anxiety. Trichotillomania most commonly occurs among children and adolescents. Women are affected twice as men. People affected by it may pull hair from any part of the body including the eyebrows, beard and body hair.

Traction Alopecia Traction Alopecia is caused by continuous pulling on the hair when styling it. This pulling causes local hair loss in the


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affected area. The factors such as various hair styles, ponytails and tight braiding are often a root cause. The process of hair loss is gradual, but if the effecting cause continues, the hair loss can become permanent. Permanent types of traction alopecia can be successfully treated with hair transplantation.

Telogen Effl uviumHair loss can happen suddenly like in the case of Telogen Effluvium. It is usually stress related hair loss, which appears as general thinning throughout the scalp. Telogen Effluvium can occur after any severe and sudden stress. In Telogen effluvium a large number of hair follicles enter the resting ( telogen) phase at once causing general hair loss or thinning over large areas of the scalp. In most cases the hair loss recovers spontaneously and completely. Telogen effluvium can be seen in patients who are prone to male or female patterned baldness and stress can cause accelerated hair loss that may be not reversible due to underly-ing conditions. The most common form of telogen effluvium is seen after childbirth or pregnancy termination in women.

Shock Loss after SurgeryThe stress and physical changes following major surgeries or procedures of head and scalp area can cause sudden hair loss in the involved areas. This is known as shock loss. Hair transplant used to be one of the major causes of shock loss, but using the medication such as finasteride ( Propecia) has reduced the rate of hair loss after hair transplant surgeries significantly.

Medication Induced Hair LossMany medications have hair loss as one of their side effects, but here is a list of the most important ones:

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● Chemotherapy mediations ● Allopurinol ● Coumarin ● Clofi brate ● Gemfi brozil ● Heparin

Scarring AlopeciaScarring alopecia can be caused by gross scars such as surgical incisions or traumatic injuries or could happen at the cel-lular level by inflammatory reactions such as skin infections destroying hair follicles. “ Alopecia “is a condition in which patients lose hair in part or all of his head or body due to destruction of hair follicles at cellular level. Cicatricial alopecia generally happens following a skin infection or inflammatory process. Scarring alopecia is as result of surgical incisions or trauma and can be easily treated with hair transplantation or sometimes with a simple excision of the scar.

Infections and Hair LossInfection used to be one of the most common causes of hair loss in children in the past, but is seen very rarely now thanks to the effective antibiotic and antifungal treatments that can cure scalp infectious diseases.

55WOMEN’S HAIR LOSS

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Given the significance of hair and its relation to a woman’s beauty in our society, hair loss in women can be even more devastating as compared to men.

However, hair loss in women is a more complex medical issue. There are various causes for the interruption of the normal hair growth in women.

The average rate of hair growth is about one centime-ter per month. The normal hair growth cycle consists of three phases; anagen (growth), catagen (transitional) and telogen (resting)

phase. This lifecycle of scalp hair can take approximately 2 to 6 years to be completed for a single follicle. After the falling of hair a new hair grows in its place. In a normal person, 85

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percent of hair is growing at any given time and the other 15 percent is resting.

The growth cycle of normal hair can change in women with hormonal changes. Most women grow their hair better during pregnancy and lose some hair after delivery of a baby. This condition is called Telogen Effluvium, which is one of the most common causes of hair loss in young women. This condition is always reversible unless the person has other underlying causes for her hair loss.

MINIATURIZATION IN WOMEN Baldness is a condition in which new hair does not grow when old hair falls or the new hair is miniaturized. Miniaturization is a state where the new hair is finer and or thinner. Miniaturization could be a precursor of hair loss and could be diagnosed with microscopic evaluation of hair and scalp. Why women lose the thickness of their hair shaft and eventually lose their hairs in female pattern baldness ( FPB) is not entirely understood. Presently, it is understood that female hair loss in the form of male or female patterned baldness are associated with genetic, hormonal changes and aging. Hormonal changes are commonly seen in pregnancy, the menopausal period and some endocrine imbalances.

PATTERNS OF FEMALE HAIR LOSSMost women lose their hair in a specific pattern that could be classified into Male Patterned Baldness ( MPB) or Female

WOMEN’S HAIR LOSS CHAPTER 5

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Patterned Baldness ( FPB). Both of these conditions are often caused by hormones, aging, and other genetic factors.

Female patterned baldness generally differs from male pattern baldness. In female pattern baldness the hair thins out more diffusely. It can also follow a central thinning that may expand to involve the entire scalp. Most women may maintain their hairline to some degree. Male Patterned Baldness usually presents itself with a recession from front and frontal corners and temple areas. It also may present itself with isolate crown balding as it could be seen in some men. Female pattern bald-ness can occasionally appear similar to male pattern baldness, but it rarely progresses to full or even near total baldness as it does in men.

PATTERNS IN WOMEN’S HAIR LOSS

Typical patterns of hair loss in women are:1. Diff use thinning with thinning in donor hair on the

back and sides ( FPB). 2. Th ese groups of patients are generally not good

candidates for a hair transplant procedure due to instability of their donor area. Medical treatment should be considered as the fi rst line of treatment.

3. Less diff use hair thinning with protected donor hair. More noticeable thinning is seen in some areas such as front, corners and crown areas ( MPB).

4. Patients in this group have the best result from hair transplant since they have an intact donor hair. Medical evaluation should be performed to check the hormonal levels particularly testosterone levels.

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5. Diff use thinning with more noticeable thinning toward the front of the scalp. Involvement and sometime breaching the frontal hairline can be noticed. Th is group can also be treated like MPB group with hair transplant if the donor hair is intact.

6. Diff used Unpatterned Alopecia ( DUPA) in which hair becomes thin diff usely without following any specifi c pattern. Th is pattern, that could be seen in both men and women, generally does not leave the patient with any intact hair on donor areas. Th ese patients are generally not good candidates for hair transplant.

OVERALL MANAGEMENT OF WOMEN HAIR LOSS

After treating women with hair loss for many years, we have established a protocol for management of women with hair loss. This approach gives a simple outline for diagnosis and treatment of many hair loss conditions in women.

Step 1: HistoryAn accurate and complete history of hair loss is the

foremost factor in treatment and management of women’s hair loss. This should include:

● a family history of hair loss especially in members of the same gender

● other previous and present medical problems ● medications that are used by the patient

When a strong family history for female hair loss is not present, it is less likely that the patient will be suffering from


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FPB. Various types of medications are known for having hair loss as one of their side effects. This is why it is important that the patient’s history of medications be carefully evaluated. However, many women do not lose hair solely after the use of medications.

Step 2: Macro and Micro- evaluationThorough scalp examination by a hair transplant surgeon should be done carefully to examine the scalp and determine the presence of abnormal pattern of hair loss. A woman presenting classic male pattern hair loss ( MPB) such as, a receding hairline or significant thinning in front with preserved hair on sides and back should be evaluated for elevated testosterone levels.

Microscopic evaluation of the scalp and hair ( miniaturiza-tion study) is an important part of every hair loss evaluation in both men and women. Microscopic evaluation guides a hair restoration specialist in monitoring the patient’s response to medical treatment.

This includes using magnification to look for the presence of very fine hair shafts in the areas of concern.

A small number of fine hairs are normally observed in people due to the natural growth cycle of hair follicles. Miniaturization (fineness) of more than twenty percent of hair shafts cannot be explained by the growth cycle of hair and other causes should be considered. The next step is the mapping of scalp hair miniaturization for all patients during their physical evaluation. This is comparing the numbers of miniaturization after months of treating patients with medication showing the effectiveness of medical treatment.

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Miniaturization and mapping of hair miniaturization is a veri-fiable guideline to evaluate the success of hair loss treatments.

In patients who are not qualified for medical therapy, min-iaturization could be used to predict the future of their hair loss. This helps a hair transplant surgeon to realize which areas to restore after foreseeing the rate of loss in different areas.

Step 3: Lab WorkConducting lab work might be necessary for many women with hair loss. This includes simple tests such as a CBC to more specific, Iron panel. Since hormonal imbalances can be the reason of hair loss and thinning in many women some hormonal evaluations should be included in hair loss evalu-ations in women too. The primary hormonal levels to check are: total and free testosterone, DHEA-sulfate, Prolactin, T3, T4 and TSH. There might be a need to check other specific tests such as ANA, if there is any evidence of autoimmune disorders that may be associated with hair loss.

In more atypical patterns of hair loss or in hair loss condi-tions without a specific family history, the doctor may need to obtain a scalp biopsy to rule out other and rarer skin conditions that may lead to a woman’s hair loss. Those conditions include autoimmune conditions of the scalp that cause hair loss such as Alopecia Areata (AA) or Alopecia Cicatricial among others. Confirming the diagnosis of those conditions helps a physician know what type of treatment should or should not be used.

Step 4: DiagnosisTreatment of female hair loss is directly related to diagnosis of their hair loss condition. If we diagnose any medical condition


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that causes hair loss in women, we can treat that condition. In many instances, discovering the cause of hair loss can allevi-ate the condition through resolving the underlying cause. In cases that we cannot find any other medical condition causing hair loss, which is majority of the cases, we treat female hair loss based on our findings in our macro and microscopic evaluation.

Step 5: TreatmentDiffuse hair loss is the most common type of hair loss in women where the patients have significant thinning or min-iaturization of hair throughout scalp. If these women still have high levels of miniaturization (fineness of scalp hair), they generally are good candidates for medical treatment with minoxidil ( Rogaine) or similar medications. Baldness could be completed. That means the patient has lost a vast majority of her hair despite having less that 20% miniaturization in the scalp hair. Patients with completed hair loss do not respond to the medical treatment.

Local hair loss or asymmetrical hair loss with loss of one area (usually the front) and preserving the donor hair on the permanent zone makes women great candidates for hair transplantation. Women’s hair transplant surgery can be very successful; provided the patients are selected properly by fol-lowing the other three steps described above.

As with all hair restoration patients, it is important to set the expectations appropriately for women with hair loss. It is crucial to make sure the patient has a good understanding of the final outcome. The level of satisfaction in women with female patterned hair loss may be quite different than with

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men with male patterned baldness. The importance of pro-viding information with realistic expectations cannot be over emphasized. Women should be informed that in some cases, more than one hair transplant procedure may be necessary to achieve the best cosmetic result.

It is important to evaluate women’s hair loss thoroughly and provide the right diagnosis. Quite often in women’s hair loss, medical treatments are used to maintain their hair rather than treating their hair loss.

Producing the original density or something close to it might be more challenging in women with extensive hair loss. Hair restoration surgery for the qualified female candidate can be a positive and uplifting life changing experience.

The combination of medical treatment, hair transplanta-tion and cosmetic changes can help create the appearance of maximum fullness in many women who suffer from female hair loss.

OTHER CAUSES OF HAIR LOSS IN WOMENThere are factors other than genetic and hormonal causes of hair loss in women. Female hair loss can also be accelerated by other factors such as:

● Telogen effl uvium, which is a temporary shedding of hair at a more than usual rate. Th is is a common cause of hair loss for men and women. Th is type of accelerated hair loss is not uncommon aft er delivery of a baby or any other stressful event.


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● Instrumental- breaking of hair (usually from aggressive hairstyling treatments)

● Alopecia areata- patchy areas of total hair loss usually facilitated by an immune disorder causing local hair loss.

● Scarring alopecia-patchy hair loss due to infection, infl ammation or injury, this is oft en followed by scarring.

● Trichotillomania- compulsive pulling of hair due to anxiety or other psychological issues. Anxiety and signs of compulsive disorder are seen in these patients.

● Hair loss as a side eff ect of some medications. ● Other skin disorders such as lupus.

MEDICAL TREATMENT OF WOMEN HAIR LOSS

Prior to treating the hair loss, all common treatable causes have to be excluded through lab testing. Rogaine (topical Minoxidil 2%) is often prescribed as the first step in medical treatment of these patients. Rogaine is the only FDA approved medication that is currently available for the medical treatment for female hair loss. Rogaine generally works better in patients who still have active hair loss. The presence of this condition can be confirmed by a microscopic evaluation of scalp. This is a very important reason why patients should only start Rogaine after being evaluated by a hair loss specialist. Nonetheless, not every woman with hair loss responds to Rogaine.

Propecia, the other FDA approved hair loss treatment for males, has not been proven to demonstrate positive results in

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women. The exception to this rule is when women lose hair due to elevated levels of testosterone. In these conditions, blocking the effect of male hormones with anti androgen medication should be accompanied with vigorous evaluation for the causes of hormonal imbalance.

Hair transplant surgery provides great results for women with hair loss when properly indicated. It is important to reit-erate, that many women with female pattern baldness are not good candidates for hair transplant. Again, this is because their donor hair area is also involved in the process of the baldness (the hair is also thinning out in that area). However, if the area of baldness is small and patient expectations are realistic some women with less than perfect donor hair can also see improvement with hair transplant. A thorough consultation and examination with a hair restoration surgeon expert in female hair loss provides the best and most successful path.

66HAIR RESTORATION

SURGERY

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A BRIEF HISTORY Baldness has been around for as long as people have had hair. Ancient archeological records suggest that even in the lofty cultures of grandeur, ancient Egypt and the more modern Roman Empire hair loss was something to hide. Elaborate headpieces and wigs were used by the noble classes of these civilizations to represent an eternal youthful appearance.

Nearly two centuries ago in Wurzburg, Germany the first written record of medical hair restoration was documented. A medical student, Diffenbach reported on an experimental surgery in which he assisted his mentor Professor Dom Unger. These surgeries were conducted on animals and humans. Their reports indicate a successful transplantation of hair from one area of the scalp to another. In the following decades however, there is little evidence to support that any surgeons utilized Unger’s technique to treat androgenic alopecia (ge-netically inherited baldness.)

It was in the late nineteenth century that hair-bearing skin flaps and grafts were first adapted in the treatment of traumatic

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alopecia i.e. baldness caused by burns or other types of severe physical injury. In this period the “traveling medicine men” peddled homemade remedies touted as a cure for baldness. These concoctions were supposed to be drunk or rubbed on the scalp. News publications of that time also touted nostrums that were a single cure all, from cancer to baldness.

HAIR RESTORATION SURGERY ENTERSMEDICAL MAINSTREAM

It was during the Great Depression of the 1930’s; that the first modern surgical techniques of hair transplantation were developed. It was in the year 1939, when a Japanese derma-tologist, Dr. S. Okuda, reported the correction of hair loss by transplanting hair-bearing skin on 200 patients. He utilized his techniques to correct hair loss on the scalp, eyebrows and the upper lip. The rest of the world did not become fully aware of these advancements and techniques until after World War II. Successful hair transplantations to areas of the body besides the scalp were also reported by Japanese surgeons throughout the 1940’s and 1950’s. The first reports in the United States to treat androgenic alopecia were not until 1959. The techniques used were remarkably similar to those discovered by Dr. Okuda nearly three decades before.

THE INNOVATION OF MODERN HAIR TRANSPLANTS

It was at this time that Norman Orentreich, MD pioneered the shaping of modern hair restoration. He presented a paper detailing the physiologic basis for successful hair transplanta-

HAIR RESTORATION SURGERY CHAPTER 6

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tion based on the concept of “ donor dominance” and “ recipient dominance.” He successfully verified his treatment for heredi-tary baldness by demonstrating that the growth characteristics of hair from the donor site would dominate when transplanted to a recipient (bald or balding) area. These principles, known as “Donor Dominance”, established that hair could be trans-planted from the bald resistant donor areas to the balding areas and continue to grow for a life time. This laid the foundation for modern hair transplantation. Orentreich’s discovery was a landmark disproving previous theories on the cause of baldness and is credited for heralding modern hair restora-tion. Over the next two decades hair restoration through hair transplants continuously gained in popularity even though the results were notably unusual.

MICROGRAFTING COMES INTO VOGUEThe Advent of Mini/Micro Grafts

The 1980’s marked another watershed event; the develop-ment of micro-grafting or punch grafts. This change rapidly evolved into even more refined donor grafts. A good example is the development of the strip method of obtaining donor hair from the back of the head; the strip would then be excised into mini-grafts containing 4 to 8 hairs. Hair restoration surgeons were then better able to create the fullness and density desired in the recipient ( balding) areas.

The artistry of some physicians began to take shape, us-ing even smaller mini-grafts of one, two, and three to create a refined feathered hairline. This advancement was significant because early grafts often yielded a brush or ‘doll like’ stiff

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appearance to the hair. Rather than dozens of grafts the new surgeries now transplanted several hundreds of grafts from the donor area to the recipient areas.

Throughout the next two decades micro-grafting tech-niques in hair transplants continued to evolve and be refined by hair restoration surgeons. Through the use of high pow-ered magnification, physicians performed very detailed labor intensive surgeries. Utilizing naturally occurring “ follicular unit groupings” of 1 – 4 hairs, the number of grafts being transplanting grew. The stead march forward of these innova-tions continued to increase the popularity of hair transplant surgery among hair loss sufferers.

Presently, FUT hair transplants are the Optimum Standard performed by the world’s best hair transplant surgeons. Relocating hair as it naturally grows has brought hair restora-tion to an exceptional level of acceptance in medical cosmetic surgery. These ultra refined follicular unit procedures enabled patients to enjoy results that are positively life changing.

21st Century Hair Restoration In the 21st century’s, the tremendous advances in microsurgi-cal hair replacement techniques have led to an increase in its popularity and effectiveness. Men and women, who suffer a loss of self-image from hair loss, benefit from hair restoration methods and procedures that help to create natural looking hair. Today’s hair restoration procedures are referred to as Follicular Unit Transplants ( FUT.) There are two forms of this surgery that will be discussed in detail in further in this chap-ter; Strip Method procedure and Follicular Unit Extraction ( FUE) procedure. It suffices to say if done right, both these


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procedures offer natural results to resolving androgenic alo-pecia or what is commonly known as pattern baldness.

THE NEW ART & SCIENCE OF HAIR RESTORATION

Follicular Unit Transplant ( FUT)The days of artificial looking hair plugs used in hair restora-tion procedures are gone. Strident advancements in the sci-ence and art of hair transplantation surgery are taking place. Follicular Unit Transplant ( FUT) is the modern state of the art standard in hair restoration. Highly successful hair restoration procedures are providing patients with remarkable natural looking results. This is because FUT involves transplanting of the patient’s own hair.

The beauty in FUT is that hair graft units are transplanted in their natural grouping from the donor scalp areas to the recipient ( balding) areas. Follicular units consist of one to four terminal hair follicles. In addition to the normal hair follicles, each follicular unit consists of sebaceous (oil) glands, a small muscle, tiny nerves and small blood vessels. Every follicular unit is covered by the surrounding sheath primarily made of collagen protein.

A follicular unit is not only an anatomic unit, but also a physiologic one. Preserving other important structures in a follicular unit ensures that each hair functions normally and looks natural. This is the basis for modern hair transplants where the natural and undetectable results are expected with every hair transplant surgery.

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Types of FUT TransplantThere are two types of follicular unit hair transplant proce-dures each with their own unique benefits and disadvantages depending on the needs of the patient. The key difference in these procedures is the way in which donor hair from the patient is harvested from the permanent zone (the back and sides of the scalp). The two types of FUT hair restoration procedures are:

1. Th e Strip MethodTh is method is the most oft en used in hair transplant procedures. A strip is taken from the permanent zone of the scalp and then the surgical wound is closed. Th e follicular units are then harvested from the strip of scalp. Th e harvested graft s are then put into recipient incisions made by the surgeon in the balding and or thinning areas of the scalp.

2. Follicular Unit Extraction ( FUE) Th is method involves having the follicular units removed from the permanent zone individually. Th e individually harvested graft s are then placed into the recipient areas of the scalp.

FUT Surgery FUT hair transplant procedures should only be performed by a medical doctor who is a hair transplant surgeon. The surgeon must be assisted by highly skilled medical techni-cians. Your hair transplant surgeon and his skilled medical team will perform hair restoration procedure, which should last for around 4 to 8 hours.


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FU, Magnified follicular units on scalp illustrating the natural grouping of hair.

Hair transplant surgery results have been significantly improved through the introduction of stereoscopic micro-scopes that are used in harvesting hair follicular units for implantation (grafts). Studies demonstrate that the increased magnification can greatly improve the quality of the grafts and maximize the yield of intact healthy hair.

BENEFITS OF HARVESTING NATURAL FOLLICULAR UNITS

● Th e ability to harvest follicular units more precisely in natural groupings reduces scarring at recipient sites in most patients.

● It creates less damage to follicles during harvesting ( transaction) and therefore a maximum number of graft s are available for transplantation.

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● Hair graft s can be placed closer together in a natural pattern creating a look of greater density.

Natural looking hair lines are created through physician skill and ability to control direction of hair growth.

THE NATURAL RESULTSFollicular unit hair transplant surgery is the gold standard hair transplant procedure because of its functionality and natural look. The natural look obtained in FUT hair restoration is primarily due to the fact that the surgeon is able to skillfully control the direction of the follicular grafts. Hair transplant surgeon can place follicular units artfully in the precise natural direction and with balanced distribution.

However, the old techniques of micro-graft, mini-graft or plugs left surgeons little to no control on the distribution and direction of each follicular unit. The way the hair units are located in the donor area dictated their final direction after the hair transplant.

Today’s male and female hair transplant patients are able to achieve a final surgical result that enhances their self-image and one that is mostly undetectable.


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BEFORE AND AFTER HAIR TRANSPLANT SURGERY

One Day Before Surgery

Dr. Mohebi designs a new, natural hairline to create a non- balding appearance.

Ten Days Following Surgery

Th e staples are removed at this phase. Some or all implanted hair will fall out and the hair follicles go to resting ( telogen) phase. However, the implanted follicles will begin growing normal hair

in a few months.

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Three Months after Hair Transplant Surgery

Gradual growth of hair follicles is seen at this phase. Th e follicles will be all out growing by six months aft er a hair transplant surgery. However, it may take over twelve months until you can see them in their best

shape and size.

Eight Months after Hair Transplant Surgery

All transplanted hair has grown by this time. Hair shaft s may not be at their fi nal length and pigmentation yet. Patients may need 10 to 18 months from the time of their surgery to be able to see the fi nal result based upon the quality of transplanted hair and the style of

their hair.


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IS HAIR TRANSPLANT SURGERY FOR ME?Whether or not you need a hair transplant surgery has to do with many different questions that an experienced hair trans-plant surgeon can easily answer by evaluating your scalp on balding and donor areas. It also may have to do with your family pattern and age of patterned hair loss presentation.

AGE OF HAIR TRANSPLANTATIONIs there an age limit to having hair transplant surgery? Unlike what was suggested in the past, there is no age limit for electing a hair transplant surgery as long as pros and cons of the procedure have been carefully evaluated by an experienced doctor. Many surgeons recommend that young men wait until they are older (above early 20s). This is because; it is the age when most men’s hairlines have matured, and better enables the doctor to predict the advancement of the individual’s pat-tern of baldness. Microscopic evaluation of the hair loss area can help a doctor to predict where the patients are heading in the future. In addition to that, availability of the new effective hair loss medications have made it unnecessary for us to wait until the patient is completely showing more advance stages of hair loss. Today, hair loss patients can now choose to have a hair transplant performed at an earlier age. This is especially important now that we know about the psychological adverse effects of hair loss on hair loss patients.

MOST MEN ARE CANDIDATES Androgenic alopecia or male pattern baldness ( MPB) is the most frequent cause of hair loss in men. MPB can begin in

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early adolescence for some young men and can be a significant source of stress for them. The risk of MPB increases with age; it is estimated that more than fifty percent of men over fifty years of age have some degree of hair loss. It is this type of hair loss that is readily mitigated through hair restoration surgery. According to research this type of hair loss affects more than thirty million men in the United States alone. It is these genetic factors that make most men with patterned baldness proper candidates for hair transplant surgery.

ONLY SOME WOMEN ARE CANDIDATES Why is it that only some women are candidates for hair trans-plant surgery? Women can also have androgenic alopecia the form of pattern baldness similar to men. However, the incidence among women is much less and most often occurs after menopause. This in many ways makes hair loss in women much more devastating.

MEDICATIONS PRIOR TO HAIR TRANSPLANT

A hair restoration surgeon’s consultation and evaluation should ascertain that there is no underlying cause of hair loss other than pattern baldness from androgenic alopecia. If hair loss is caused from other conditions such as Telogen Effluvium that can occur post pregnancy the condition must be treated first. It can occur after other types of stresses in men or women. This and other types of hair loss conditions should be treated prior to moving forward with a hair restoration surgery.


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BODY DYSMORPHIC SYNDROME Body Dysmorphic Syndrome is a condition characterized by excessive pre-occupation with an imaginary or minor bodily defect. In some people the condition is severe enough to cause a decline in the patient’s social, occupational, or educational functioning, this is seen with some patients who believe they are suffering from hair loss when a complete medical evalua-tion demonstrates that they are not. It is very important that a hair transplant doctor evaluates the patient to confirm the diagnosis and to ascertain the need for a hair transplant surgery.

MENThe majority of male hair loss sufferers are men. As we said before, Male Pattern Baldness ( MPB) is by far the primary cause of hair loss in men. By the age of fifty, more than fifty percent of men have noticeable hair loss. The percentage increases dramatically each decade. By the age of seventy years nearly ninety percent of men experience noticeable hair loss from androgenic alopecia. This hereditary genetic factor makes many men great candidates to enjoy the natural benefits of hair restoration. Hair transplant surgery is becoming the preferable choice for many.

The donor hair for men is taken from areas that are natu-rally resistance to MPB in most cases. Donor hair primarily resides at the back and sometimes the sides of the head. These hairs when transplanted to balding areas most often thrive and provide the patient with satisfying results.

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WOMENHair loss in women is in many ways different than in men. For this reason, a few women suffering from hair loss find hair transplant as the best option. Women typically lose hair at a more diffused pattern all over the scalp. This is often described as thinning and not balding by female hair loss suf-ferers. However, there are a significant number of women who inherit pattern baldness. These women can take advantage of the advancements in hair transplant surgery and technology to achieve a wonderful solution to their hair loss.

EVALUATION BEFORE HAIR TRANSPLANTA thorough evaluation including scalp and hair microscopic assessment, also known as the miniaturization study, should be part of an initial evaluation for every hair loss patient. Obtaining personal family history regarding baldness is critical in making the proper diagnosis. A detailed history should be taken, that includes the time, speed and quality of hair loss and its associa-tion with other medical, physical or emotional factors.

A history of past and current medical problems is particu-larly useful in women with female pattern baldness because it helps discover any treatable disorder that may have caused or accelerated the process of hair loss. Some of the most common disorders are: iron deficiency, thyroid disorders, autoimmune diseases such as lupus and hormonal imbalances for example, an increase in male hormone or altered estrogen or proges-terone levels. Some medications could cause hair loss in both men and women in which case, a more detailed history of medication use would be obtained.


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Miniaturization study or recording the hair caliber changes on a microscopic level is used to diagnose most common hair loss patterns. Microscopic evaluation is also used to predict future hair loss. The initial evaluation includes measurements of donor quality and scalp laxity. Those two factors are key to patients who undergo hair transplant procedure.

The kind of result a person should expect after hair trans-plant surgery has to do with many factors. It is mostly related to the characteristics of the hair in the donor area. These characteristics include: thicker hair vs. thinner hair, wavy vs. straight and minimum contrast of hair color with the skin tone. Less contrast means less visibility of the scalp and less appearance of baldness.

An examination is important because it helps the doctor to determine a person’s qualifications for hair transplantation and to estimate the number of grafts needed.

HOW DOES A HAIR TRANSPLANT WORK

Hair restoration through hair transplant surgery is the only natural permanent solution for androgenic alopecia. As dis-cussed before, hair on the back and sides of the head is referred to as the permanent zone. It is because the hair in those areas is genetically resistant to baldness. The permanent zone is also known as the donor area. Hair from donor area is transplanted to the bald areas (recipient area) for hair restoration.

This success of using genetically resistant hair from a permanent zone is the reason why the hair transplant surgery

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trend has been on the rise in the last few decades. This pro-cedure is also becoming more popular among women. Hair transplantation is being used for eyebrow hair loss or to restore hair on any other part of the body that a patient desires.

Hair restoration can also be used for treatment of hair loss due to physical injuries including burns, congenital deformi-ties and surgical scars that cause hair loss.

Today, there is only one natural solution to hair loss; that is hair restoration through hair transplant surgery. These procedures for eliminating hair loss involve the surgical re-moval of donor hair from the back and or sides of the scalp to the thinning and balding areas. Today’s microscopic hair transplant surgery is so refined that it is mostly undetectable.

Hair is harvested from the donor area in its natural group-ing of one to four hairs. These groupings are called follicular units. Hair transplant surgeons make artful incisions into the recipient ( balding) area(s.) The results of modern hair restora-tion are highly successful and natural because it is the persons own hair restored in a natural realistic pattern.

Hair restoration surgery has been the preferred choice of treatment for male patterned baldness ( MPB). The tremendous recent advances contributes to the growth of hair transplanta-tion for others including female pattern baldness ( FPB), eye-brow hair loss or restoring hair on any part of the body.

It is important for people to know that the surgical proce-dures used in hair restoration must be performed by a medical doctor who specialize to perform hair transplant surgery.


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STRIP METHOD HAIR TRANSPLANTThe strip method procedure is the most widely performed hair transplant surgery used in hair restoration for men and women. You will also hear this mentioned as follicular unit transplantation ( FUT). In fact, there is only one specific form of FUT. Strip Method is the best choice of hair restoration for most people because the individual hair follicles stay intact and they are very rarely damaged by this technique. This is because, the natural follicular units remain intact throughout harvesting and implanting. The follicular units contain 1 to 4 hairs with the normal average being 2.2 hairs per follicular unit.

When performing the strip method procedure the hair transplant surgeon uses microscopes allowing for refined dissection of the each hair follicle. The lack of heat generated by these microscopes further preserves the integrity of the harvested follicular units. Each unit is preserved in a special temperature controlled solution while the doctor designs the recipient sites.

Follicular Unit dissection and placement of graft s

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CRITICAL FACTORS IN STRIP METHOD PROCEDURES

In medical procedures, there are numerous factors that lead to a successful outcome. The qualifications, knowledge and expe-rience of the surgical team provide hair restoration patients with a lifelong attractive natural result. These critical factors include:

● Correct donor extraction and wound care ● Excellence in follicular unit dissection ● Quality control in graft preparation ● Graft hydration and storage ● Age appropriate, natural hairline design ● Recipient site creation using proper angulations,

direction and arrangement ● Careful placement of graft s with the proper technique ● Diligent post-surgical follow up at appropriate

intervals

Dissecting the strip into grafts is key to maximizing the number of available donor follicular units and optimizing all other results in a patient’s hair transplant. A strip is dissected into smaller pieces called slivers (see images). Next, the slivers are dissected into follicular units or grafts. In our offices, well trained teams ensure that grafts are not wasted due to poor technique. Proper dissection results in a high level of hair growth after hair transplantation.


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Double hair and triple hair FUT samples.

FOLLICULAR UNIT EXTRACTION ( FUE)

What is FUE? Follicular Unit Extraction ( FUE) is the method of harvesting hair grafts directly and individually from the patient donor area. This process of collecting hair units was first introduced by Dr. Woods in Australia. Other hair transplant doctors further standardized it.

Follicular Unit Extraction ( FUE) may also be called Follicular Isolation Technique (FIT). One of the advantages of FUE is that patients will not have a linear scar on the donor area of the scalp. In FUE or FIT, the strip of skin from the donor area is not removed. Patients do not experience donor complications seen with the strip technique such as pain and discomfort in donor area after hair transplant. There is no need for staple or suture removal after the procedure and there won’t be a linear scar in the area.

The History of FUEJapanese doctors are known to be the first to describe how skin containing hair could be moved from one area to the other while keeping its ability for growing hair. They performed the initial

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successful transplantation of the hair follicles in order to treat the scars and burn patients in the 1930s by transplanting small pieces of skin to those areas. Dr. Norman Orentreich, a derma-tologist in New York City, demonstrated the theory of donor dominance in 1959. He proved that plugs of skin, with hair fol-licles from the back of the scalp, can continue growing hair after being implanted into balding areas. He has since performed the initial plug transplantation in America. Those initial plug surgeries are the ancestors of the current FUE transplantation.

Dr. Woods from Australia was the first doctor who har-vested single follicular units using smaller punch devices. His smaller size punches allowed transplantation of the individual follicular units without removing a plug or a strip of skin. He presented his surgical technique of using 1mm punch in 1995. Despite the novelty of his technique his attempt to publish this method in medical journals was not successful.

Drs. Rassman and Bernstein were the first physicians who jointly published the methodology of harvesting hair follicles, as we call them Follicular Unit Extraction or FUE, in 2002. FUE method of removing individual follicular units was first performed with larger punches (larger than 1mm). In recent years more modernized methods and the use of smaller punches were introduced to the field of hair restoration. The non-invasive nature of FUE procedures and the possibility of eliminating the linear scar has made it a very popular method of hair transplantation in the last few years. Currently, there are several motorized devices such as suction assisted harvest-ing techniques and robotic arm in the market for harvesting follicles with FUE method.


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FUE versus Strip Hair Transplant FUE transplant techniques have been improved tremendously in the last decade. However, both FUE and strip hair trans-plants are still being used and they each have their advantages and disadvantages. The option of choosing one method versus the other should be evaluated after a thorough examination of the hair loss situation by a hair transplant surgeon.

Choosing FUE transplant versus strip method involves several factors including the total number of permanent donor hair in relation to the number of hairs that the person may require during life. The patient should make the final deci-sion about the type of hair transplantation based on factors such as the extent of hair loss, quality of donor hair, and the patient’s expectations. Here we will review the most common advantages of each technique:

FUE Transplant Advantages ● It does not leave a linear scar on the donor area so the

patient can choose to keep hair on the back of their head very short or even shaved

● Th ere is very minimal pain and discomfort aft er FUE transplant.

● Th ere is a minimal chance of donor complications such as wound necrosis or temporary hair loss aft er hair transplant (shock loss) in donor area aft er FUE procedures

Strip Transplant Advantages ● A higher number of graft s can be harvested in one

procedure in strip transplants. Today we can easily transplant over 2500 graft s in most patients in their fi rst

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hair transplant procedure with the strip method. Th is number can be signifi cantly higher when the density of hair is higher and the scalp is loose on the donor area.

● Many patients can achieve their goals and maximum number of graft s with fewer strip procedures

● Strip hair transplant is generally more aff ordable than FUE transplants. Th e cost of FUE could be about twice as much as Strip FUT in most practices due to its labor intensity

● More viable graft s are expected to grow from follicular units that are harvested with the strip method. Th is is due to the minimal rate of follicular transection that might be seen in FUE procedures

It is advisable that every hair loss patient chooses the option for hair transplantation only after reviewing all the pros and cons of strip versus FUE hair transplant methods. It is also important for hair transplant surgeons to consider individual hair characteristics, demand for hair, and the patient’s personal goals when selecting the right hair transplant procedure.

Who is a Good Candidate for FUE? FUE can be recommended for almost any one. People who want to have the option to shave their head or wear their hair very short may have no other options. Although the linear scar caused by strip could be minimized by a variety of techniques of wound closure, there is still no way to guarantee the line of scar will not be visible if the patient chooses to shave his head.

People who only need a small number of grafts to restore limited areas of the scalp are among those who may want to


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choose the FUE procedure. Although there are many tech-niques that allow us to increase the number of grafts that could be harvested in one session, the number of grafts per day in FUE procedures are still not comparable to the strip procedure.

Another group of the patients who may want to choose FUE are those who have had a bad experience in the past with complications of a strip procedure or those that have significant scarring, and the removal of more follicles through strip is impossible.

Diff erent Methods of FUE FUE devices and methods have been transformed consider-ably in the last two decades. Manual methods, which are still in use by some clinics, have been refined with more perfected punches. There are a variety of sharp and dull punches and a combination of them. Motorized methods of FUE harvest-ing have been around for many years. They include rotating versus oscillating that could be utilized with sharp versus dull punches.

Some of the motorized FUE devices are equipped with a suction mechanism to extract grafts after they are punched from the scalp. There have been controversies on the benefits of adding suction to the FUE machines. This is because of the potential negative effect of the suction on the viability of the grafts.

Finally, Robotic Hair Restoration is another innovative device in the field of hair restoration. The robot allows de-tection of the follicular units and its topography with several

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cameras. The images from the cameras can detect the loca-tion, distribution, and the angulation of the follicular grafts. The robotic arm has been able to increase the speed of graft extraction and more importantly to minimize the exhaus-tion of the surgeon during a FUE hair transplant. Despite the advantages of robotic hair restoration systems, there are still some disadvantages to it such as, the size of the punches are still relatively large in comparison to what is used in other methods of FUE. The high price of the device is another disadvantage, sometimes totaling up to the whole price of the cost of a hair transplant.

FUE Complications FUE hair transplant like any other surgical procedure has its complications. Here are some of the common complications of a FUE transplant:

● Transection of hair follicles:Th e most common complication of the FUE procedure, especially if it is not done in the right hands or with the proper technique, is the high rate of transection. Transection is the dissection of the graft s somewhere along its length that prevents extraction of an intact follicle. Transection rate may be higher with some devices in comparison to others. It may also be higher in wavy hairs. It seems that many of the transected graft s will grow in the donor area.

● Hypopigmentation: Th is is when the spots of the harvested FUE graft s look lighter than the neighboring areas. Th is complication may only be seen when the patient


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keeps his/her hair very short or shaves his/her head. Th is condition is usually not seen as much when smaller size punches are used. Hypopigmentation could be treated with Scalp Micro pigmentation ( SMP), which adds dermal pigments that resemble hair and minimize the visibility of the lighter areas.

● Folliculitis/Cyst formation: Th is condition happens when the hair follicle in the donor or recipient area becomes infl amed. Th is may be due to the closure of the exit pores of the oil glands that naturally occur around hair ( sebaceous glands). Folliculitis may look like atypical facial acne and is usually dissolved spontaneously without any treatment. If it persists the doctor can incise and drain the pimples in the offi ce.

● Ingrown hair:Ingrown hair might be occasionally seen in the donor area especially when the follicular transection rate is higher than normal. Th e lesions occasionally require incision and removal of the trapped hair that can be done easily in a doctor’s offi ce.

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FIRST FEW DAYS AFTER HAIR TRANSPLANT

Pain and discomfortThere may be some aching in the donor area, which starts within the first few hours after hair transplantation. Pain medicine is provided to alleviate the discomfort during the first night. After the first night, the pain should be well con-trolled. Most patients do not need any medications for pain after the first day, but if they are still experiencing pain during the second day, mild pain medications such as Tylenol, in most cases, is enough to bring more comfortable results.

SwellingSwelling is very common on the first four days after hair restoration surgery. Some swelling around the transplanted area is expected. Swelling is due to the process of healing and may range from non-existent to severe in which the subcuta-neous fluid descends from the forehead area to around eyes. Maximum swelling is generally seen in days 3 and 4 after hair

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trans plantation. Some patients may need steroids to prevent swelling after their hair restoration. It is good to sleep in a semi-sitting position and keep the upper body elevated, which will help minimize the swelling, or shorten its duration.

BruisingBruising or discoloration of skin around the transplanted area might be present for the first few days after the procedure. This may involve the recipient area, and at times, may extend to the forehead. Covering the transplanted area with a hat can hide the area of swelling, but those with existing hair can use it to cover the bruised areas of the transplanted sites.

ScabbingScabbing is common during the first week or two after a hair transplant. The scabs should flake off within one week if the patient washes the transplanted areas properly. It is a good practice to bring patients back for the first day after hair transplantation to give them a hair wash and teach them how to wash their head for the first few days. Special shampoo and sponge is needed for proper washing of hair that may vary in different practices. We recommend washing transplanted areas twice a day for the first 4 days. Patients can go back to their routine hair wash after that time unless they continue to have scabbing. They need to continue washing their head twice a day, as long as they still have scabbing in the area.

ItchingItching is a common symptom in any type of wound healing. Hair trans plantation is not an exception to that reality. Patients may feel itching on transplanted and donor areas for the first few

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days. This may extend to the second week after hair transplant. However, it should be mild and does not require any treatment for most patients. If itching is significant, then a prescription of a moisturizing cream or a mild steroid cream might be needed.

Washing Hair After Hair TransplantThe first 4 days after surgery are most critical, as hair trans-plant patients need to be extra careful about washing their hair, especially the transplanted areas. There is a special “hair washing” appointment the day after surgery designated to show the patient how to properly wash, with critical care of the transplanted areas. After 4 days most people can return to a normal hair washing routine.

Returning to Work After Hair TransplantYou can return to work as early as the day after hair restoration surgery, but if the job requires any kind of lifting, bending, stretching, physical strain or touching chemicals, patient should take a few days off until the acute phase is over. Some patients may need to take days off only because they want to keep their hair transplant surgery confidential. In these types of cases patient can take 1 to 2 weeks off work. The first four days are the most critical when being extra careful to avoid any type of strain, after four days the transplanted grafts are usually well settled and they cannot be dislodged.

Physical Activities After Hair TransplantNo physical activity that can cause strain on the back of head, sutured, or stapled area should be done. There are no limita-tions for mild exercises as long as the patient does not bend his/her head aggressively or touch the transplanted area.

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Contact sports should be avoided for the first month for most patients who had a transplant surgery.

ONE WEEK AFTER HAIR TRANSPLANTRedness and Infl ammation The inflammation and redness should be subsided at this time, but a mild pinkish discoloration of the transplanted area may remain. This can be visible for a few weeks and could be com-parable to a sunburn, especially in patients with lighter skin.

Physical ActivityIt is okay to resume exercise more than two days after the hair transplant. It is critical to be selective about the types of exer-cises are done (such as not doing squats, bent rows, lifts, etc.) for the first four days after surgery. Always aim to keep your head elevated and upright when possible. Bending the head may increase the tension of the donor area in strip procedures that may increase the chance of stretching of the scar.

ItchingItching is still common during this time as the surgical areas will continue healing during the first few weeks.

FOUR WEEKS AFTER PROCEDURERedness and Infl ammation The inflammation should be subsided by this point in most patients. Transplanted hair generally falls out in the first two to three weeks and patients go back to where they were before hair transplantation at this point.


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Physical ActivityPatients should be able to resume most physical activities they used to do before hair transplantation. The key is avoiding strain on the scar area if a strip, or FUT, hair transplant was performed. If an FUE procedure was performed, then more intense exercises are permitted.

3 MONTHS AFTER SURGERYAppearance Patient’s appearance should be similar to pre-transplanted time. Patients generally don’t keep the newly transplanted hair, and commonly lose the shaft of hairs while the follicles become part of the scalp and generate new hairs.

Shock LossThis is the worst period after hair transplantation due to the fact that some patients may lose some of their native hair due to shock loss after their hair transplant. This happens when the bulk of the transplanted hair grown in yet. Some patients may feel like the bulk of their hair is lessening more than what it was before the hair transplant. This does happen at times until the next few months after hair transplant when the patients can see the newly transplanted hair along with regrowth from some of the hair that has gone through shock loss.

New GrowthPatients, who have complete baldness with no visible hair before hair transplant, should be able to see some very small hair in the transplanted area. Many people may not see any new hair begin to grow out before the first six months after the procedure.

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Folliculitis Folliculitis or pimple shaped lesions may be noted in some patients at this time. They generally form because of the collec-tion of sebum (oily secretions of the hair follicles). Folliculitis lesions usually drain spontaneously without any need for any interventions. If folliculitis lesions are more than two or they are painful, you need to see your surgeon to have those lesions drained for you. Drainage of folliculitis is generally simple and painless.

6 MONTHS AFTER SURGERYTelogen Effl uviumTelogen Effluvium is sudden and usually stress related hair loss, which presents itself as general thinning throughout the scalp. Telogen Effluvium occurs after any severe and sudden stress. In Telogen effluvium a large number of hair follicles go to sleep phase at once causing hair loss or thinning all over or in a large area of the scalp. In most cases the hair loss recov-ers spontaneously and completely. Telogen effluvium can be seen in patients who are prone to male or female patterned baldness and stress could accelerate hair loss that may be not reversible due to underlying conditions. The most common form of telogen effluvium is seen after childbirth or pregnancy termination.

ONE YEAR AFTER SURGERYHair Growth The final results from the hair restoration should be obvi-ous and noticeable at this stage. Most of the new hair will


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have grown to its normal thickness at this time. Although most patients may see most of their results at this time, more improvement in fullness and thickness should be expected up until 18 months from hair transplant. The size of the donor scar will mature during the first year and should be at its final size at this time in patients who had the strip hair transplant procedure.

AFTER THE FIRST YEAR OF SURGERYMore fullness should be expected at this point through 18 months from the hair transplant. This case is especially true for the patients who grow their hair long. Many patients at this time can see the final result and determine whether a second hair restoration procedure is necessary.

It is crucial to stay in touch with your hair transplant sur-geon after your hair transplantation if you have any concerns or questions. We at US Hair Restoration usually want to see our patients after their hair transplant surgery for 4 standard follow up visits.

HAIR TRANSPLANT RESULTSMost people experience the loss of the hair shaft in their newly transplanted hair grafts whitin the first few weeks. It may take 2-3 months for the patients to see the regrowth of the new hair. Occasionally this can be up to 6 to 8 months. Full results of the hair transplant surgery can be seen after 10-12 months after surgery in majority of the patients.

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The results of a hair transplant with follicular unit trans-plantation should be undetectable. That is, if the procedure is done correctly with proper techniques and by a qualified hair transplant surgeon. Most patients report that even the hair stylists cannot tell that they had a hair transplant done. The ability to take follicular units with 1, 2, 3 or 4 hairs allows for the surgeon and medical team to place hair follicles into recipient sites in a natural and realistic direction and distribution. The undetectable natural and permanent results of the modern hair transplants provide patients with results that truly uplift their self-image and esteem (Mohebi & Rassman, 2008).

This success also can change the results for patients who had hair transplants before the advent of FUT procedures. These older procedures with very detectable results can be repaired and restored with the skill of an experienced hair restoration surgeon.

HAIR TRANSPLANT COMPLICATIONSHair transplant is generally a skin level surgery therefore its side effects are minimal and limited to the skin level. Here are the most common complications of a hair transplant surgery:

PAIN AND DISCOMFORTPatients may have pain after a hair transplant surgery on the donor site. That is where the surgical wound is closed with either suture or staples. Tightness of the area can also be a problem especially in the cases that a large number of grafts are removed. Patients generally do not have any pain in the recipient area after a hair transplant procedure. Pain is mostly


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seen after strip hair transplantation as we discussed before; FUE patients usually do not experience any significant pain.

Donor pain can be controlled by blocking the area right before the conclusion of the procedure with infiltration of local anesthetics. The block that is obtained by infiltration of local anesthetics may wear off after a few hours after the hair transplant. Many patients may need pain medication for the first night after the surgery. The pain usually subsides the following day, but discomfort of the sutured or stapled area on the back may remain for several days. Mild over-the-counter pain medication is generally sufficient to alleviate the pain in following days.

SWELLING AND INFLAMMATIONLike any other skin surgery, hair transplantation may cause swelling or redness for the first few days. The difference is that hair transplant swelling is usually not seen immediately after the hair transplant, but it starts to be noticeable at around days 2 and 3. The swelling typically reaches its peak on days 3 and 4 and subsides immediately after that. Sleeping in a semi-sitting position like in 30 to 45 degrees for the first few nights can help minimizing the swelling. Swelling can be severe and move down to the areas around the eyes, but cannot jeopardize the survival of the grafts. If you have a high risk of swelling based on your prior surgical history, you may need anti-inflammatory medications to minimize the redness and swelling after a hair transplant. Steroids could be prescribed by your hair transplant surgeon to be used before or after your procedure.

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SHOCK LOSSShock loss is losing hair in an area with active hair loss due to stress. Shock loss after hair transplants used to be more common. However, it has been proven that using finasteride ( Propecia) can prevent shock loss considerably. Minoxidil may have a similar effect on minimizing shock loss in areas with active hair loss. This may be a consideration in some women who undergo a hair transplant.

We recommend starting the patients who have high risk of shock loss on one of these medications a few days before hair transplant and continue for at least 6 to 8 months after the procedure.

Shock loss can also be seen around the donor area. Donor wound shock loss is mostly seen in the patients who require a large number of grafts and the ones with a tight scalp. Hair loss around the donor area is more common among women due to the smaller proportions of their head circumference to the width of the strip.

Shock loss is a type of telogen effluvium in which a large number of hair follicles enter their resting phase at the same time. Growing hair follicles that are forced to enter a resting phase lose their hair shaft temporarily. This hair thinning may continue for a few months, but it usually resolves completely without any need for treatment.

FOLLICULITIS Folliculitis is a pimple-like skin lesion that is seen when hair follicles become inflamed for any reason. Folliculitis is one


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of the common complications of a hair transplant surgery. Folliculitis usually occurs due to blockage of hair or its seba-ceous gland when a newly transplanted follicular unit is heal-ing in its new location. Folliculitis after hair transplantation usually appears as small, red or white-headed pimples around one or few follicular grafts. Folliculitis may present itching, mild pain and minimal discharge. Most cases of folliculitis clear spontaneously in a few days. More aggressive types of folliculitis may need medical or surgical interventions.

Folliculitis may be seen a few days to months aft er a hair transplant surgery. Th e presence of folliculitis usually does

not aff ect the growth of the transplanted hair.

Occasionally, the lesions of folliculitis may become painful or their appearance may bother the patient. Simple drainage of the lesions is the only treatment most patients need. A

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physician’s evaluation can best determine whether or not the patient needs antibiotics for the treatment of folliculitis after hair transplant.

DONOR SCAR Hair transplant requires removal of the hair from donor area. Harvesting hair could be done through either strip or FUE method. Strip hair transplant involves removal of a slice of scalp and closing it. The closed wound generally leaves a linear scar after healing. The strip scar is not visible unless patient decides to shave his head or to keep it very short. There are many procedures that could minimize the appearance of donor scar. One procedure that we perform on most patients is trichophytic closure.

Trichophytic closure is when a small wedge is removed along the edge of donor wound before closure. This allows some hair to grow inside the donor wound rather than next to it. Presence of hair follicles in the donor wound minimizes the contrast the scar has with its surrounding areas of the scalp with dense hair. Trichophytic closure could be done on one or both edges of the wound. Doing trichophytic closure on both edges can increase the density of hair that grows inside the scar. This can minimize the visibility of the scar further. Trichophytic closure may result in a donor scar that is almost undetectable in some patients.

The visibility of the donor scar in strip method can be further reduced through a small FUE procedure. In this proce-dure the scar is filled with FUE grafts minimizing the contrast of the scar with neighboring areas of the scalp. Transplantation


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of FUE into the donor scar can be done a few months after the initial surgery once the donor wound is completely healed. Usually a very small number of FUE grafts are needed to improve the appearance of the scar. This procedure can be completed as a short outpatient procedure.

Other procedures such as medical scalp pigmentation could also be used to further minimize the visibility of the donor scar in a patient who requires to shave their head in the future.

Unlike strip procedures, FUE hair transplant does not leave a linear scar. FUE may result in small dot-shaped scars. The scars of FUE may not be visible due to the size or the scattered pattern they have. Some patients may develop hypopigmentation in the areas that the grafts are removed without any obvious scarring. Scalp micropigmentation or medical tattooing can be used to improve the appearance of the FUE donor scars or hypopigmentation if they occur.

NUMBNESSNumbness of the scalp could occur after a hair transplant procedure. Numbness could be present in the recipient or donor area. Numbness could happen due to irritation of the sensory nerves of scalp that run under the skin at donor or recipient area. The initial numbness of anesthetics injections may resolve in a few hours. However, the numbness may occasionally persist for days or in rare cases months after a hair transplant. No treatment is needed for the numbness and recovery is usually complete in most patients. Injury to some sensory skin nerves may cause permanent numbness in

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one area of scalp. This condition is extremely rare and could be avoided in most cases with using the proper technique of surgery.

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EYEBROW HAIR TRANSPLANT Eyebrow hair transplant is a relatively simple and safe procedure. Eyebrows functionally protect your eyes and are not just a mere cosmetic facial feature. The advance methods of modern hair restoration allow for the

creation and restoration of natural looking brows. People who have scars in the brow area or the ones who have lost the eyebrow hair are generally very happy to take advantage of an eyebrow hair transplant procedure.

CAUSES OF EYEBROW HAIR LOSSThe following are often causes of eyebrow hair loss in men and women:

● Congenital inability of growing eyebrow hair. Th is condition is seen in many members of a family and is easily treated by eyebrow hair transplantation. Some

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ethnicities may present this type of eyebrow loss more than others.

● Physical trauma such as burns and other accidental injuries.

● Over-plucking or repeated reshaping of eyebrows. ● Continuous damage to the eyebrow follicles in some

sports such as boxing. ● Medical disorders such as thyroid diseases. ● Autoimmune disorders such as alopecia areata or

lupus. ● Trichotillomania which is an obsessive disorder causing

the person pluck his or her hair obsessively. Th is could happen to the eyebrow, eyelashes or any other parts of the body that have hair.

A hair transplant can effectively restore partial or total eyebrow loss in various conditions. Hair transplant can only be considered when the underlying medical condition for the hair loss is under control. Hair loss from Trichotillomania cannot be transplanted unless the psychological condition is completely treated and when the condition is under control.

EYEBROW HAIR TRANSPLANT PROCEDURE

Eyebrow transplant is done through harvesting scalp hair from the back of the scalp just like a scalp hair transplant. The removed skin is dissected with microscopic magnification to follicular units. Hair can be harvested with conventional strip techniques or FUE. However, we recommend strip method

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for eyebrow transplantation to be able to follow the curvature of the hair shafts individually.

After harvesting the donor hair, the recipient area is pre-pared and small incisions are made in the recipient area. Very tiny incisions produce a tight grip for the follicular unit grafts that are harvested. Angulations of eyebrow hair with sharp angles and their special alignment make eyebrow transplanta-tion more intrinsic than general scalp transplantation. In order to create the best natural results and making the eyebrows normal looking, direction and distribution is very important.

The growth of transplanted hair in eyebrows follows the pattern of scalp hair growth. Transplanted eyebrow hairs grow constantly needing to be trimmed more often than normal eyebrow hair. Patients may need up to around 300 follicular unit grafts for each eyebrow depending the extent of the hair loss area. The number of hair grafts may vary based on patient’s sex and ethnic background and individual facial fea-tures. The eyebrow hair transplantation is usually performed under local anesthesia and some sedation.

Complications after an eyebrow transplant are minimal. Bruising, swelling and scabbing can be seen during the first few days after an eyebrow transplant. They usually subside in 3 to 5 days after the procedure. Daily washings will minimize the amount of scabbing and facilitate healing of implanted hair grafts. Newly transplanted hair to the eyebrow area usually falls out in the first 2 weeks. Patient should be able to see new hair growth from those follicles in about 3 to 6 months. Full results are expected after 6 months from the time of eyebrow transplantation in most people.

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EYELASH HAIR TRANSPLANTWe are often enamored with the eyes of a person. Eyelashes are correlated to beauty in women and men. It is important to note that eyelashes have an anatomical function. They shield the eye from injury. Primarily they are a filter for larger and microscopic particles in the air such as dust and grit. The eye protection afforded by eyelashes is very important.

CAUSES OF EYELASH LOSSEyelash hair loss may be due to many causes. Here is a list of the common causes of eyelash hair loss:

● Industrial accidents resulting in chemical and thermal burns

● Physical trauma due to injuries ● Adverse results from cosmetic enhancements such as

eyelid tattoos, and traction alopecia associated with long-term use of false eyelashes

● Surgical treatment of injury or tumor that results in removal or eyelash follicles and tissue scarring

● Medical treatments such as radiotherapy or chemotherapy for cancer treatment that results in hair loss

● Trichotillomania which as described before is a compulsive hair plucking condition

● Other skin conditions causing hair loss such as alopecia areata or alopecia universalis

● Congenital absence of hair eyelash

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EYELASH TRANSPLANTATION TECHNIQUE

As in all surgical hair transplantation “living grafts” or hairs follicles are harvested from a donor area or permanent zone (located on the back and sides of the scalp). The transplanted hair will continue to grow in the eyelid the way they would grow in the scalp. The curvature of the transplanted hair is carefully aligned with natural curvature of eyelash hair. Some patients may have to follow a training program for curling the transplanted hair to match the natural curl of their normal eyelashes.

Trimming the hair is always required to maintain the op-timum length for the best look and functionality of eyelashes. The preferred method of removal of hair follicles for eyelash transplant is through strip procedure since hair should be kept long. The reason for that is the need to be able to follow the curve of each hair and implant them with proper angle. The strip removed for an eyelash hair transplant is very small due to the small amount of hair needed.

MEDICAL TREATMENT FOR EYELASH RESTORATION

Eyelash enhancement has become a popular cosmetic medical treatment. Advancements in understanding the class of drugs known as prostaglandin analogues has lead to the rise of this elective medical treatment. Latisse (bimatoprost ophthalmic solution 0.03%) is a relatively new product that has recently gained a lot of popularity. The medication was originally

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used to treat the increased eyeball pressure in glaucoma. The ophthalmologists noticed stimulated growth and darkening of the patient’s eyelashes.

Latisse increases the length of time that hair follicles stay in the growth phase. This helps the eyelashes to grow for a longer periods of time and more eyelashes stay in growth phase. This creates longer lashes and more hair density to the eyelashes. Latisse is a great medication for people who want to have thicker fuller eyelashes. This type of medication will not work if the patient has permanently lost their eyelash hair follicles. Eyelash hair transplant is presently the only proven solution for people who have lost their eyelash hair follicles.

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Comparison of scalp (left ) vs. facial (right) hair: Note the diff erence in density of hair per surface area and the average number of hair in each follicular unit. Scalp hair is denser with more hairs per graft s (over 2hair/graft ) while beard hair is less dense with fewer hairs per graft s (1-2 hair/graft )

FACIAL TO SCALP HAIR TRANSPLANTOur hair grows all over our bodies except on the soles of our feet and the palms of our hands, lips, and eyelids; of course eyelashes are an exception. The utilization of hairs from all over the body for hair transplantation into scalp has been in practice for many years. Though many men have what

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appears to be an exceptional supply of donor body hair there is a drawback to extensive use of body hair in hair restoration surgeries.

BODY HAIR LIFECYCLEThe difference in the life cycle of body hair from different areas of the body makes it one of the last options for scalp hair restoration. Body hair has a long resting phase and a short growth phase, which means that most of the transplanted hair will stay in resting phase without having visible hair growth.

Facial hair such as the beard and mustache hair on the other hand has a longer growth phase and shorter resting phase. That is why men can grow their facial hair to become really long. Facial hair is also thicker than scalp hair in most people. Thicker hair could be translated as more bulk of hair after hair transplantation. Both longer growth phase and thicker hair shafts make beard hair a better option for scalp hair restoration in comparison to body hair transplant from other areas.

Anagen Catagen Telogen

Scalp Hair 2-6 years 2-3 weeks 2-4 months

Body Hair 4-7 months 3-4 weeks 9 months

Eyebrows 4-7 months 3-4 weeks 9 months

Eyelashes 4-7 weeks 2-3 weeks 3-9 weeks

Male Facial Hair 1 year 2-3 weeks 7-10 weeks

Pubic Hair 4-8 weeks 2-3 weeks 2-3 months

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There are two problems with beard hair restoration. One is that they are very sparse and removing hair can only be done through FUE procedure.The other problem with using facial hair for scalp transplant is that the facial follicular units are having fewer numbers of hairs per unit that means less hair per grafts removed with FUE techniques.

FACIAL HAIR TRANSPLANTSAlternately, beard transplants are gaining popularity with the successful advanced techniques of FUE extraction of hair grafts.

People may lose facial hair due to: ● scaring and other scar conditions ● Th ey may not have the ability to grow their mustache

or beard genetically ● Th eir natural beard pattern is sparse and or uneven

In many of these situations, facial hair can be success-fully restored with a hair transplant using scalp hair through follicular unit transplantation. We are also able to use some beard hair for transplantation into the mustache area below the nose above the upper lip.

In instances where there is a mismatch between the thick-ness of scalp and beard hair shafts we use either strip follicular unit transplants or FUE ( Follicular Unit Extractions) to har-vest hair for mustache hair restoration.

One of the better options for a patient is to use beard hair as the donor source for a FUE procedure. This is most often

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preferred to avoid facial scarring. The number of needed grafts for the patient is determined by the width of the upper lip and also the shape of moustache that is most proportional with their other facial features.

The cost of facial hair transplantation for mustaches and beards generally follows the same per graft cost as scalp hair transplantation. Results of a mustache hair transplant can be seen as early as 4-6 months following the hair transplant and may continue to improve one year after surgery.

BODY HAIR TRANSPLANT Follicular Unit Extraction ( FUE) can remove hair from any-where in the body as long as you are tested positive for FOX in those areas. FUE procedures are more labor intense and more time consuming so the cost is almost double in comparison to regular strip hair transplant procedures.

Neck hair is not the best option for hair transplantation because those hairs may fall out in older patients. We can use body hair for hairline, the front or even the crown, but you may need multiple surgeries to obtain adequate density in the recipient areas using body hair. As previously noted, body hair has a long resting phase in relation to its growth phase. Therefore you will have more follicles in resting phase ( telogen phase) that do not have any visible hair in comparison to the ones in growth phase ( anagen phase) that provide you with actual hair and give you coverage.

Body hair can be considered as an alternative method of hair restoration as long as you, the patient, understands

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that the end result is not going to be comparable with a scalp hair transplant. This is due to smaller final length of hair and short growth phase (Anagen) as opposed to long resting phase (Telogen) that characterizes body hair. In other words, you may only see a portion of the transplanted hair follicles in growth phase while the remainder stays in resting phase without maintaining a visible hair shaft.

Beard hair transplantation can be a better option, which is generally closer to scalp hair in many patients and has a longer growth phase (which is why it grows to become longer in comparison to body hair). It should be noted that each of these options have pros and cons and patients should be evaluated. It is important that a hair restoration treatment plan is based on the patients needs and supported by a complete evaluation by a hair transplant surgeon.

FOX TESTA Fox Test is conducted to determine whether a patient is a suitable candidate for direct extraction of hair follicles, known as follicular unit extraction ( FUE). This is a form of Follicular Unit Transplantation ( FUT) for hair restoration surgery. If hair follicles are easily removed without transection (damage) to the hair follicle, then the patient can opt for FUE hair resto-ration procedure. The test consists of having a small biopsy performed in which the patient’s hair follicles are carefully examined to see if direct extraction will render them viable as donor hairs for transplantation.

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FACIAL FEMINIZATION SURGERY (FFS)Hair restoration is helping meet the needs of self-image for many patients. Patients going through the transgender process who may have a full head of hair often desire to have their hairline to be more feminine. This framing of the face is a large part of their self-image, how they view themselves and how they present themselves to the world.

Hair restoration surgeons are dedicated to take the ad-vancement of medical science and make them applicable in as many ways as possible for the benefit of their patients. Developing the hairline for transgender patients is meticulous for male to female transgender patients. Many such patients undergo a scalp advancement to move the hairline forward and reduce the depth of the brow typical to male physiognomy.

Today’s leading hair transplant surgeons can easily repair the hairline in front of the scar of a transgender patient who has had scalp advancement surgery. It is important not to alter the hairline previously with hair transplant when opting to undergo scalp advancement surgery. If there is less than

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perfect transplanted hair on the hairline, the hair transplant surgery for feminizing the hairline will be more difficult. This requires removing the hair grafts that are transplanted out of their normal locations and reuse them in the other areas.

SCAR REVISIONSince the advent of hair restoration surgeries, hair trans-

plant surgeons have been managing and mitigating the chal-lenge of scalp scars from strip hair transplants. Patients may also have a linear scar after undergoing other surgical scalp procedures or neurosurgical operations. Trauma can also be a source of scarring to the head. Although most scars are hidden in patient’s native hair, some may become exposed due to their proximity to the hairline or when a patient keeps his hair short.

The size, type and location of scars can determine the techniques available to a surgeon seeking to minimize the ap-pearance of a patient’s scar. We have created an algorithm that hair transplant or other cosmetic surgeons can use towards the most effective methods to address scalp scars and the proper surgical or medical approach to them.

FACTORS THAT ARE BEING TAKEN INTO ACCOUNT FOR A PATIENT’S SCALP SCAR REVISION ARE:

● Th e prior history of scar occurrence ● Th e patients’ reaction to injuries in other parts of the

body.

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A proper physical examination can reveal what propor-tion of the visibility of scar is due to stretching or hypertrophic reaction and what portion has to do with hair transection.

The scars that are wider than what is expected might have some components of stretching. To improve the visibility of stretched scars the surgeon needs to use a technique to mini-mize the contrast between the hairless scar and neighboring areas of the scalp by bringing hair inside the scar.

● If you only need to revise the scar and get trichophytic closure to minimize the visibility of the scar, one surgery is adequate.

● Double-edged trichophytic closure is a new technique that can improve the appearance of the scar tremendously.

● If you are aft er achieving higher densities and scar revision, you may need several hair transplant procedures if you have enough donor hair for them.

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EXPECTATIONS FROM MEDICAL HAIR LOSS TREATMENTS

There are many hair loss remedies and products in the market. However, a vast majority of hair loss treatments that are being marketed today are still nothing but “snake oils.” A few effec-tive medications for hair loss have been around for over two decades. The development of 5-alpha-reductace inhibitors for treating prostate enlargement marked a landmark break-through in hair loss treatment. It is the conversion of the male hormone testosterone to dihydrotestosterone ( DHT) that causes health complications in the prostrate. Likewise, Overtime DHT destroys many hair follicles which is the root cause of male pattern baldness. DHT blockers along with Rogaine are the only two types of medications that are FDA approved for treatment and prevention of patterned baldness.

5-ALPHA-REDUCTACE INHIBITORSThere are two powerful medications that were developed for the inhibtion of DHT; finesteride and duasteride. These two

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medications initially used for the treatment of prostate issues such as Benign Prostatic Hyperplasia (BPH). During trials of these 5-alpha-reductace inhibitors a positive side effect was noted as prevention of hair loss and in some instances hair growth. After specific research on hair loss, finasteride ( Propecia) garnered FDA approval for the treatment of male pattern baldness. It is now possible to slow down the progres-sion of androgenetic alopecia ( male patterned baldness) using finasteride. These discoveries along with hair transplants advancements represent the proven answer to hair loss today for many men with typical male pattern baldness. Below is a review of these FDA approved medications and other treat-ments that are used to combat hair loss .

PROPECIA ( FINASTERIDE) Finasteride is the generic name for the brand name medica-tions Proscar and Propecia. Finasteride; initially produced by MERCK under the name Proscar to treat enlarged prostate glands in men. A slightly modified version of Proscar was produced with smaller dose to medically treat hair loss.

Finally in December 1997, the FDA approved a 1mg dose of finasteride for the treatment of androgenetic alopecia or typical male pattern baldness in men. The majority of men who used Propecia have witnessed slower hair loss and even hair growth.

Side effects from finasteride at the 1-mg dose are uncom-mon. In initial studies, the one- year drug related side effects were 1.5% greater than in the control group. The data from the research indicated 3.8% sexual dysfunction in men taking

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finasteride 1mg experienced verses 2.1% in men treated with a placebo.

HOW FINASTERIDE WORKS Finasteride specifically inhibits 5-alpha-reductase, the enzyme that converts testosterone into a more potent androgen dihy-drotestosterone ( DHT). After initial studies on a daily 1 mil-ligram dose of finasteride it was proven that it:

● Lowers DHT levels in the scalp signifi cantly when taken on a daily basis

● Minimizes the progression of hair loss in majority of men taking the drug during clinical trials

● Promotes a substantial increase of hair growth in trial participants

In last two decades most hair restoration doctors have recommended finasteride as the first line of medical hair restoration for men.

ROGAINE ( MINOXIDIL) Minoxidil was approved prior to Propecia by the FDA for the treatment of male pattern baldness. The pill form of minoxi-dil ‘Linotien,’ was widely used to treat high blood pressure. Researchers discovered that the people taking the medication were growing hair on face and other areas of the body.

Researchers came up with the idea that applying topical minoxidil directly on the scalp, might grow hair on balding areas. And it did, but to varying degrees depending on the

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extent of the hair loss. This was a revolutionary step in the treatment of hair loss at that time.

Rogaine ( minoxidil) has no effect on the hormonal pro-cess of hair loss. The positive effects of minoxidil on hair growth usually end with cessation of use. In many cases, patients may even experience the loss of hair that has been kept due to the effect of the medication. This phenomenon is called catch up hair loss.

Although Rogaine is recognized as an effective treatment for a some hair loss sufferers, most doctors do not recommend it as the first line of attack for men suffering from male pattern baldness. The reason behind it, is the result of some side by side studies that had compared topical minoxidil with oral finasteride. These studies have clearly shown oral finasteride as a more potent option for treatment of male patterned baldness.

HAIR RESTORATION MEDICATION SIDE EFFECTS

Minoxidil and finasteride are the two FDA approved medica-tions for hair restoration. Millions of people now choose this medical treatment to effectively reduce hair loss. In addition finasteride (PROPECIA) is prescribed in our advance tech-nology US Hair Restoration centers throughout Los Angeles. Finasteride is very effective pre and post hair transplant sur-gery. It does not matter which form of follicular unit transplant ( FUT) a patient is electing. It is effective whether one is having a ‘Strip Method’ surgery or FUE hair transplant.


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As with any medication it is important to understand the possible side effects no matter how rare. As finasteride is a successful and strategic hair restoration medical treatment that we employ in our centers, it is important to clarify the possible risks or side effects of this treatment.

FINASTERIDE ( PROPECIA)The side effects from this treatment are not as common as ‘urban legend’ would have people to believe; actually they are relatively uncommon. Studies show that when a patient uses the most often prescribed 1 mg dose the reported side effects were reversible. In fact it is of most significant to note that after a one year study of the drug related side effects were much greater than the placebo control group. Finasteride side effects were only 1.5% greater in the group actually taking the medication.

Sexual dysfunction was the reported side effect by men in the control group. During the study the percentage of men in the control group with that complaint was only 3.8%. This is compared to 2.1% of men with the same complaint in the placebo group during the year-long study. In addition a 5 year side effects profile yielded the following statistics: decreased libido reported in 0.3%, erectile dysfunction reported at 0.3% and decreased volume of ejaculate at 0.0%.

SEXUAL DYSFUNCTIONThe general word out there is that impotence is a common side effect in men taking finasteride. However, the scientific

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data does not report it to the degree of severity that we often hear about from patients in our clinics.

Based on the research data reports, sexual dysfunction oc-curs at the onset of the medical treatment. In some instances it is reported later. It is important to note that within a few weeks after cessation of the treatment, the sexual dysfunction side effects were reversed. Nearly sixty percent of all men staying on treatment noted that the side effects subsided.

The idea that sexual dysfunction continues after stopping the medi cation has yet to be substantiated in studies. So, de-spite urban myth these reports are not based on clinical trials and need to be confirmed with well designed medical research.

HAIR LOSS GAINSDuring the study of finasteride no significant drug interactions were identified in clinical studies. It was noted that hair would return to previous levels of hair loss after the medication was stopped.

LONG-TERM BENEFITS AND RISKSThe benefits of finasteride are strictly to scalp hair which is thinning or undergoing miniaturization. Finasteride does not restore fully miniaturized hair follicles. This means that if baldness is complete it will not work. Thinning scalp hair or miniaturizing hair is halted and other scalp hair does not begin the process of miniaturization. This means it is not effective for people who are completely bald; its primary benefit is to slow down or stop hair loss from male pattern baldness.


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Best results are reported for the first year of use and a modest decrease in second year of use. Long term benefits are still unknown and men who have taken finasteride for five years still report that it still works.

OTHER HAIR LOSS TREATMENTS FOR WOMEN

The most common type of hair loss in women in which patients have significant thinning or miniaturization of hair throughout scalp is known as Female Patterned Baldness ( FPB). Female patterned baldness is generally characterized with diffuse hair loss. Women who have diffuse miniatur-ization (fineness of scalp hair) may be good candidates for medical treatment with minoxidil ( Rogaine).

Women with more advance hair loss may not respond to the medical treatment. Some women with non-diffused hair loss who have preserved hair quality on some areas of their scalp can be good candidates for hair transplant surgery. Many of these women may be suffering from male patterned hair loss in which they preserve the quality of hair on the back and side of scalp while losing it in other areas.

Many women may lose their scalp hair due to other medi-cal conditions that also may present with diffuse hair loss. Diagnosis of this type of hair loss could be made with labora-tory work or scalp biopsy in most of these women. Depending on the type of hair loss, a hair loss specialist may elect one or a combination of these options.

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Diagnosis MPB (local balding)

FPB (Diff used thinning)

Other medical conditions

Treatment Hair transplantAnti-androgen - if hyperandrogenism exists

RogaineCosmetic change

Treat underlying condition

Table 1: Association of each diagnosis of female patterned hair loss with its treatment options

In addition to medical and surgical treatments an expe-rienced hair specialist can cosmetically help women through cosmetic changes such as microfibers ( Toppik, Caboki) and scalp coloring agents ( DermMatch). The proper use of the cosmetic products and hair styling should be part of most hair loss consultaions. A hair specialist may also review the options for hair style for maximum coverage and to hide the thinning areas of the scalp. At times when the hair loss is very advanced and the patients are not candidates for medical or surgical treatments of hair loss, wigs or synthetic hair systems may be the last solution.

CONCEALERS FOR HAIR LOSSThere are two popular kerontinized fiber products used to create the illusion of thickness for thinning hair and early baldness. Microfibers such as Toppik and Caboki are used by many women in different stages of hair loss. These products are sprinkled into the thinning area and worked through into the hair style creating the illusion of more hair. The idea is that the small microfiber can attach itself to the hair shaft and make them look thicker as well as coloring the scalp to


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minimize the contrast between the hair color and skin tone. The drawback is that these products can come off on clothes and furniture when touched. Similarly there are sprays to minimize the contrast between the scalp and hair color by painting the scalp surface.

FOUNDATIONS OR COVER UPS Foundation products similar to those used on the face are sometimes used on the scalp. Foundations are used when there is not much visible hair in one area like men who have only a blading spot on the crown area. An example of those products is DermMatch that could be used by people who suffer from appearance of a balding patch on their scalp. By choosing a color close to the individual’s hair color minor thinning or baldness can be blended with a cover up. Like microfibers and sprays these products can come off after use.

LASER FOR HAIR LOSSResearch on laser treatments for hair loss is not yet definitive enough for many hair restoration doctors to justify its use. These devices are currently available without a standardiza-tion of form and functionality. Here are some of the available options for hair loss treatment:

● Laser comb ● Laser hood ● Laser hat

There has been anecdotal information on the effective-ness in some of these devices. Those are mostly the ones with

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adequate amount of laser beam. People with diffuse hair loss like many women with female patterned hair loss seem to benefit best from it. The laser cap treats entire scalp with 224 individual red 5mw – 650 laser diodes some hair loss special-ists and the patients are reporting positive results. Despite the reports on their effectiveness in some patients, more research is needed before any of the laser devices could find its place as an effective hair loss treatment.

1212ADVANCEMENT IN HAIR RESTORATION

TECHNOLOGIES

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STEREOTACTIC MICROSCOPEThe concept and application of the follicular unit transplan-tation ( FUT) makes it possible to create completely natural hairlines. The introduction of the stereotactic microscope is one of the key advancements that made the current refined transplanted results a reality. Stereotactic microscopes help the surgical team to be able to visualize the follicles three dimensionally. Microscopic three dimensional visions help the extraction and separation or more refined follicular units (FUs) while minimizing the risk of damage ( transaction) to the hair follicles.

Studies show that microscopic harvesting of FUs can minimize the damage to the hair grafts significantly. The refinement of the results from hair transplantations has in-creased the demand for hair restoration surgery in last two decades. Today’s results are so natural that even hair stylists cannot detect them.

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MEGASESSION AND GIGASESSION HAIR TRANSPLANTS

In addition to the increase in the quality of the hair transplants there has been a high demand for transplant procedures with a larger number of grafts. Megasession hair transplants (over 2000 grafts) or gigasessions transplants (grafts over 3500) are new advancements in hair transplantation. In these procedures a surgeon can restore a large balding area in only one session. The time involved in each hair transplantation combined with the long waiting period to see the full results makes multiple surgeries unattractive to patients. Mega and giga sessions can eliminate the need for additional surgeries in most cases.

Of course hair transplants with large number of grafts require special techniques and skills. A more efficient surgi-cal team is also required for those procedures. Many factors should be considered during a large hair transplant procedure. Minimizing the time that hair follicles have to stay out of body is vital in larger procedures. Introduction of sequential strip removal (Parsa Mohebi 2010) in which the strip is removed in two sections rather than one can reduce the time grafts stay out of body to half. Sequential strip removal can increase the survival of the grafts by minimizing the time they spend out of body.

Calculating the maximum safe number of grafts is one of the crucial elements. This calculation has been facilitated using the Laxometer (Parsa Mohebi 2007) which measures the free mobility of the scalp so the surgeon knows how much of the scalp skin is safe to remove.

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LAXOMETER

A laxometer is a device invented and developed by Dr. Parsa Mohebi for measuring the scalp laxity more precisely. Scalp laxity is a crucial factor in most hair transplant procedures, which are performed with the removal of a donor strip from the permanent zone at the back of the head. These donor hairs are genetically resistant to the adverse effects of DHT on hair follicles. Hair transplant surgeons used to measure the laxity of the scalp manually. The surgeons often recorded the mobility of the scalp before hair transplants with terms such as loose, moderate and severe tightness. Manual measurement of the scalp laxity was an approximate gauge and was not always accurate.

The Laxometer is a measuring device that is used to calculate the laxity of the scalp. An accurate measurement of scalp laxity is critical when determining how wide the donor strip can be. This breakthrough in hair transplant technology allows surgeons to determine a precise measurement. In the case of a less desirable scalp laxity the number can be verifiably

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increased as a result of patients doing daily scalp exercises. The patient’s improved scalp laxity allows for the removing of a larger strip of scalp increasing the number of FUs available for hair transplantation.

MOTORIZED FUE TRANSPLANTSIn the last few years, we have been witnessing the emergence of several motorized FUE devices. These devices were developed to solve the following issues with FUE procedures:

● high transection rate ● slow speed of graft s extraction ● the trauma on scalp tissue

Independent comparison studies to ascertain the success levels of these devices in resolving these issues have been mini-mal. Presently hair restoration surgeons adopt one or a few of these methods to provide their patients with the best results.

FUE TRANSPLANT WITH SAFE SYSTEMThe advanced improvements in modern hair transplantation techniques provide better results for hair restoration patients. Follicular Unit Extraction ( FUE) traditionally has been done through punching out hair grafts manually. In this procedure, a very small punch device assists the surgeon in removing the follicular units from donor area. The manual removal of the follicular units could be time consuming and at times provide low quality grafts. The newer and more modern technique of hair restoration provided a variety of motorized devices that help the surgeon remove grafts at a higher speed and better


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quality. Several different motorized devices are available in the market. Some of the motorized devices that are used to harvest follicular units are: SAFE system, NeoGraft, Cole system etc.

We performed an experiment on different motorized ( SAFE System and NeoGraft) and manual techniques of Follicular Unit Extraction ( FUE) in our Los Angeles hair transplant center in 2010. The result of our study was in favor of SAFE system in comparison to the other two studied methods. SAFE System helped minimize the risk of damage to the follicular grafts while removing them with a reasonable speed. Since then, we have been using SAFE System in most FUE hair transplants.

Powered SAFE System for FUE is a relatively new device for minimally invasive FUE procedures. SAFE system has been proven to have higher yield of healthy hair follicles due to a lower graft transection rate. SAFE hair restoration system uses a blunt punch instead of a sharp punch. Not having a sharp punch might attribute to the less damage to the hair follicles in SAFE method.

ROBOTIC HAIR TRANSPLANT Robotic hair transplant system was introduced at the 19th Annual ISHRS Scientific Meeting for Hair Restoration sur-geons. The more popular techniques require using a more automated tool known as the ARTAS System. ARTAS is an FDA approved surgical tool for use in the United States. ARTAS was developed to help meet the need for increased precision and speed in scoring the follicular grafts in Follicular Unit Extraction ( FUE) hair transplants. This is considered an innovative and fairly new technique in hair transplantation.

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In this technique, the robot can locate the follicular units and punch them. Robotic hair restoration currently only assists in one step of hair restoration process which is the scoring the follicular grafts. The scored grafts still have to be harvested manually by the surgeon or surgical technicians.

ROBOTIC HAIR TRANSPLANT RESEARCH CONTINUES

Despite the vast progress in making new automated methods for harvesting hair, we still do not have a perfect system that can both extract and transplant the hair grafts automatically. The current ARTAS System has the promise of increased speed of the FUE hair transplant procedure thus it can increase the number of grafts available in single procedure. It also could be assumed that the robotic hair restoration can minimize the effect of human error and the negative consequences of operator exhaustion.

More research is anticipated reviewing the quality of trans-planted hair by a robotic system in comparison to the other available methods of FUE. Future advancements in robotic procedure may include methods to also assist with implanting the hair grafts. A more complete automated system can defi-nitely make robotic procedures more appealing and practical.

STEM CELL AND HAIR MULTIPLICATIONHair multiplication or hair cloning is a method of multiplying hair follicles and generating a larger number of donor hairs for transplantation purposes. The growth and development of


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hair follicles is regulated by two types of stem cells residing in each hair follicle, those are the Dermal Papilla and the Bulge area stem cells. Scientists have been attempting to replicate hair cells and create more hair for transplantation purposes in and out of the body.

Although the initial studies show the success of hair mul-tiplications in the lab, the research for hair multiplication has been progressing very slowly due to many factors:

1. Hair loss has detrimental eff ects on patients’ lives. However it has not yet been recognized as a crucial medical problem in order to warrant more funding for hair loss research.

2. Hair multiplication studies are usually done in private settings without the support of larger medical institutions such as universities and NIH ( National Institute of Health).

3. Th e duplication time for hair stem cell is extremely slow in cell cultures. Th is makes the overall period of hair cell duplication timelier which adds exponentially to the duration and cost of most hair stem cell studies.

The stem cell studies for multiplying hair should go through different phases. The last necessary phase in development of every new medical treatment is ‘ clinical trials’. This phase is done on volunteer patients with long term follow-up. This is to evaluate the risk of long term complications associated with the treatment. We are not aware of any hair cloning study that has reached the clinical trials. This makes it unlikely to have any hair cloning procedures available to public in the next few years.

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GENE THERAPY A NEW FRONTIER IN HAIR RESTORATION

Gene therapy is still in its infancy. To date, there are only a few examples of gene therapy success in the treatment of alopecia. Still, gene therapy represents the newest frontier in medical hair restoration treatment.

Gene therapy could be one of the most perfect techniques for solving patterned baldness. It is the process of altering cell function by changing genes that are responsible for unwanted traits. Gene therapy requires learning how an inherited medi-cal condition occurs at the DNA molecular level. Hair follicles with DHT-sensitive cells could be changed into follicles with DHT-resistant cells with gene therapy. This makes it pos-sible for the hair follicles to continue growing new hairs for a lifetime.

Gene therapy involves several very difficult steps to achieve a viable medical treatment for baldness.

1. Th e fi rst step is to determine which genes among the tens of thousands of genes on strands of DNA are involved in the characteristic for hereditary alopecia.

2. Th e next step will be to fi gure out how to alter the targeted genes to give instructions for making the slightly diff erent proteins that will achieve the desired eff ect.

3. Th e fi nal step is getting the target cells in the patient to incorporate the new and improved genes as replacements for the old undesirable genes.


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GROWTH FACTORS FOR HAIR GROWTHGrowth factors are important in the process of hair growth. We need to identify the necessary growth factors in the pro-cess of hair loss in order to be able to control the process. We know that lack of some growth factors is responsible for hair loss in men and women. This means that we should be able to modulate the hair development system by manipulating the levels of growth factors.

Utilizing PRP ( Platelet Rich Plasma) for hair restoration is a concept that was developed based on the effects growth factors could have on the growth of human hair.

More studies are necessary to identify the necessary do’s and effective timing that growth factors should be used for hair restoration or to slow down the process of hair loss.

NEW MEDICATIONS FOR HAIR RESTORATION

Medications that are presently approved to combat hair loss are Rogaine ( minoxidil) and Propecia ( finasteride). These medications counteract androgenic alopecia or genetic pat-terned hair loss. Both these medications require ongoing use for the best results. Both finasteride and minoxidil can slow down the process of hair loss, but they are limited and may not be able to restore someone’s hair to its full density in the long run. The result is significantly expensive over time and also poses a risk of some adverse reaction from long-term use.

As doctors and scientists improve their body of knowledge on how the hair cycle works and how it is controlled meta-

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bolically and genetically, they will be able to discover more effective products that help hair loss sufferers.

A current medication on the market, Duasteride, pre-scribed to treat benign enlarged prostate glands could also be used for hair loss soon. Dutasteride is proven to be more effective than Propecia. Dutasteride is also prescribed under the brand name Avodart.

Dutasteride is a 5-alpha-reductase inhibitor that is taken as a pill. Dutasteride has been shown to dramatically reduce the levels of DHT by blocking the conversion of testosterone. Elevated levels of DHT can also cause enlarged prostate glands in men over time.

Narrowing targeting and while reducing side effects is the next level in increasing the overall effectiveness and desir-ability of hair loss medications. The future could also hold the opportunity to develop topical lotions for scalp application that more effectively block the DHT.

In the future we will be able to better affect the DHT levels in the cells in the hair follicles. This may result in bet-ter control hair loss and can reduce unwanted side effects of these medications. It is highly possible that medications of the future will be combined with shampoos or hair conditioners, and these products will become a common way to keep hair loss at a minimum.

It is clear the future of hair loss treatment holds great promise, from new medications, the advances in hair cloning and in gene therapy. These treatments are years, or maybe


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decades away before FDA approval and before they are avail-able for practical treatments.

The great news is that today’s treatment methods, includ-ing drugs such as Propecia, and surgical procedures such as follicular unit transplantation ( FUT) are available now, pro-viding natural and permanent solutions for hair loss. These methods are sufficient for many men and women to restore and maintain a full head of hair without the need to any other treatments.

1313OTHER SCALP PROCEDURES

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SCAR REVISIONGoing bald negatively affects a person’s self image and esteem. The effects of scalp scars are likewise adverse on a person’s well-being. One of the most rewarding aspects in hair restora-tion is the positive impact that a successful hair transplant has on the happiness of patients. Scar revision also has this type of profound effect on many people who suffer from unwanted scalp scars.

First and foremost, we believe in prevention. A properly selected wound closure technique and utilization of proper instruments can make a difference in the final appearance of a scalp scar. In some instances, scar development is inevitable and the surgeon needs to know how to manage a scar to re-duce the visibility of scalp scars. Based on the type of scar we recommend several methods of scar revision:

Simple Scar Revision Due to technical or congenital issues the donor scar can become wide as it heals. The scar can be provisioned with a simple minor surgery. A simple scar revision is performed by

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the surgeon removing the old scar, followed by closing the wound edges with the proper technique in one or two layers.

Scar Revision and Trichophytic closureThe surgeon removes the scar and closes the wound in a manner which allows hair to grow inside the scar. The even-tual growth of hair minimizes the contrast between scar and surrounding areas of the scalp.

FUE TransplantUtilizing follicular unit extraction ( FUE) we are able to take a small number of donor hairs (as needed) from the permanent zone of scalp. The harvested follicular unit grafts are care-fully implanted inside the scar. Since FUE is the individual removal of hair units, there will be minimal to none scarring at the areas that grafts are removed. The newly transplanted hair blends the scar making it almost undetectable in most cases. Some people may need more than one surgery for the optimum result.

SMP ( Scalp-Micro Pigmentation) In this procedure fine needles are used to insert dermal pig-ments in the skin to create the illusion of stubble hair within the scar. The pigments are chosen to emulate the color of the person’s hair. This non surgical method of scar revision reduces the visibility of scar.

SCALP REDUCTIONScalp reduction was once a common procedure among hair loss procedures. The availability of follicular unit transplanta-tion with undetectable results had made scalp reduction obso-

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lete. Today’s leading hair restoration centers utilize advanced technology and sophisticated techniques that produce more natural and undetectable results. There are perhaps some rare exceptions when this procedure could be an alternative for example in burn scars or congenital scalp lesions.

This surgery was initially described in 1977 by Drs. Blanchard and Blanchard. Scalp reductions reduce the size of the bald area by excising a substantial portion of bald scalp and suturing. Dr’s. Martin Unger and Walter Unger recommended a combination of scalp reduction and modern hair transplant. They believed the use of these procedures improved their overall results for hair restoration. Scalp laxity is very critical to the success of scalp reduction and for the same reason it is not a good solution for many people who do not have adequate scalp laxity.

SCALP MICRO-PIGMENTATION ( SMP) Scalp Micro-Pigmentation is a non surgical cosmetic proce-dure that uses special dermal pigments to create the illusion of hair or hair stubble. Fine needles are utilized to inject the pigment into the upper dermal layers of the scalp. This cre-ates the shade of stubble or shaved hairs on the scalp. Dermal pigments are selected that match the patient’s hair color. SMP is employed in scar revision in the scalp and in other areas such as the eyebrows. The success of SMP procedures is in the blending it creates while simulating short hairs. SMP has been also used to cover large areas of a balding scalp and for filling in eyebrows.

AAAPPENDIX

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PATIENT 1

Class VI hair loss. 12 months elapsed aft er a hair transplant with 3288 graft s.

PATIENT 2

Class IV hair loss. 6 months elapsed aft er a hair transplant with 2544 graft s.

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PATIENT 3

Class III hair loss. 12 months elapsed aft er a hair transplant with 1326 graft s.

PATIENT 4

Class VII hair loss. 12 months elapsed aft er a hair transplant with 3702 graft s.

APPENDIX

145

PATIENT 5


PATIENT 6


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PATIENT 7

Class VI hair loss. 6 months elapsed aft er a hair transplant with 3251 graft s..

PATIENT 8


APPENDIX

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PATIENT 9

Class VII hair loss. 10 months elapsed aft er a hair transplant with 2805 graft s.

PATIENT 10

Class VII hair loss. 10 months elapsed aft er second hair transplant with total of 5612 graft s.

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PATIENT 11

Class FPH hair loss. 6 months elapsed aft er second hair transplant with total of 4740 graft s.

PATIENT 12

Class FPH hair loss. 6 months elapsed aft er second hair transplant with total of 4740 graft s.

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PATIENT 13


PATIENT 14


150


PATIENT 15


PATIENT 16

Top Th inning hair loss. 12 months elapsed aft er a hair transplant with 3477 graft s.

IIINDEX

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Symbols5-alpha-reductase 45, 119, 136

Aactive ingredients 28advancement 47, 63, 71, 113advancements 16, 43, 44, 62, 65, 74,

118, 127, 128, 132advances 40, 43, 64, 76, 136age limit 71aging factor 11, 12Allopurinol 50alopecia 21, 22, 24, 27, 29, 30, 32, 33,

39, 43, 49, 50, 59, 61, 62, 65, 71, 72, 73, 75, 102, 104, 118, 134, 135

Alopecia 29, 41, 48, 50, 54, 56, 59alopecia areata 21, 102, 104American hair industry 11, 12ANA 56anabolic steroids 31Anabolic steroids 23, 31anagen 39, 48, 51, 110Anagen Effl uvium 48analogues 105anatomic unit 65

androgenic alopecia 21, 29, 32, 43, 61, 62, 65, 72, 73, 75, 135

Androgenic Alopecia 29, 41androgens 38, 39, 40anecdotal evidence 16Anorexic 21anthropological evidence 17anti androgen 60antidepressants 20antifungal 50anxiety levels 13, 14ARTAS 131, 132ARTAS System 131, 132asymmetrical hair loss 57atypical patterns 56autoimmune conditions 56auto-immune disease 48autoimmune disease 21autoimmune diseases 74Autoimmune disorders 102Avodart 136

Bbalding 12, 15, 23, 27, 28, 32, 33, 34,

35, 43, 46, 53, 63, 65, 66, 69, 71,

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73, 74, 76, 80, 119, 124, 125, 128, 141

Baldness 3, 32, 40, 42, 43, 44, 46, 52, 53, 57, 61, 73, 123

Beard hair transplantation 111behavior 9, 13birth control pills 20blood 26, 27, 30, 33, 65, 119Blood thinners 20blood vessels 65Body Dysmorphic Syndrome 4, 73Body Hair 5, 108, 110bulimic 21

CCaboki 124catagen 51CBC 56Chemical 27chemotherapy 20, 39, 48, 104Chemotherapy mediations 50Cicatricial alopecia 50circulation 26, 27, 28, 29, 30circulation problems 28clinical observations 13clinical trials 32, 119, 122, 133Clofi brate 50Cole system 131collagen 65condition 15, 18, 20, 23, 24, 29, 41,

42, 43, 48, 50, 52, 56, 57, 59, 72, 73, 85, 100, 101, 102, 104, 124, 134

congenital 76, 139, 141Congenital absence 104consultation 11, 12, 16, 60, 72Cortex 38Coumarin 50Cuticle 38

Ddandruff 28

defi ciency 24, 31, 33, 74degree of hair loss 9, 72depression 13, 24dermal papilla 38Dermal Papilla 133DermMatch 124, 125DHEA-sulfate 56DHT 33, 35, 38, 39, 45, 117, 119,

129, 134, 136diagnose 56, 75diagnosis 54, 56, 58, 73, 74, 124Diff enbach 61Diff used Unpatterned Alopecia 54diff use hair loss 123, 126dihydrotestosterone 38, 39, 117, 119disease 9, 21, 22, 39, 48dissection 77, 78, 84DNA 134dominance 63, 80donor 28, 53, 54, 57, 60, 63, 64, 65,

66, 68, 71, 73, 75, 76, 78, 79, 80, 81, 82, 84, 85, 87, 88, 90, 93, 95, 96, 98, 99, 103, 105, 108, 109, 111, 115, 129, 130, 132, 139, 140

Dr. Bernstein 80Dr. Blanchard 141Dr. Martin Unger 141Dr. William Rassman 13Dr. Woods 79, 80dry scalp 28duasteride 117DUPA 54

Eeconomics 11, 12eff ective treatments 34eff ects 12, 15, 20, 29, 34, 45, 46, 49,

55, 71, 94, 118, 120, 121, 122, 129, 133, 135, 136, 139

Egypt 11, 17, 61emotional problems 11, 12Emotional problems 12environmental factors 19

INDEX

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enzyme 45, 119epithelial cells 28esteem 11, 12, 14, 16, 43, 94, 139estrogen 74evaluation 16, 19, 28, 29, 32, 35, 36,

52, 53, 55, 57, 59, 60, 71, 72, 73, 74, 75, 98, 111

evidence 16, 17, 31, 34, 56, 61examination 55, 60, 75, 81, 115eyebrow hair loss 5, 76, 101Eyebrow hair transplant 5, 101Eyebrow transplant 102Eyelash enhancement 105Eyelash hair transplant 106

FFacial hair 108fact 17, 30, 34, 35, 68, 77, 91, 121facts 3, 17, 18, 35family history 35, 54, 56, 74family pattern 71FDA 43, 45, 46, 59, 117, 118, 119,

120, 131, 137FDA approved 43, 45, 46, 59, 117,

118, 120, 131female hair loss 23, 52, 54, 56, 57, 58,

59, 60, 74Female Hair Loss 3, 52female/male pattern baldness 24Female Pattern Baldness 40female patterned baldness 41, 49,

52, 92female patterned hair loss 26, 57,

124, 126fi nasteride 5, 47, 49, 96, 118, 119,

120, 121, 122, 123, 135Finasteride 5, 34, 47, 118, 119, 120,

121, 122fi nesteride and duasteride 117follicular graft s 68, 84, 97, 131, 132Follicular Isolation 79Follicular Unit 4, 47, 64, 65, 66, 77,

79, 80, 109, 110, 111, 130, 131

Follicular Unit Extraction 4, 64, 66, 79, 80, 110, 130, 131

follicular unit groupings 64follicular units 66, 67, 68, 76, 77, 78,

80, 82, 83, 94, 102, 109, 127, 130, 131, 132

follicular unit transplantation 77, 94, 109, 127, 137, 140

follicular unit transplants 14, 109Folliculitis 5, 85, 92, 97Foundation products 125FOX 5, 110, 111FPB 40, 41, 43, 52, 53, 55, 76, 123,

124FUE 4, 6, 64, 66, 79, 80, 81, 82, 83,

84, 91, 95, 98, 99, 102, 109, 110, 111, 120, 130, 131, 132, 140

FUE extraction 109FUE method 80, 98FUE procedure 83, 84, 91, 99, 109FUE procedures 80, 81, 82, 83, 110,

130, 131FUE transplant 81, 84fungal infections 21FUT 47, 64, 65, 66, 68, 77, 79, 82, 91,

94, 111, 120, 127, 137FUT hair restoration 66, 68FUT hair transplants 64

GGemfi brozil 50genes 32, 41, 43, 46, 134Gene Th erapy 6, 134genetic 21, 22, 28, 31, 32, 33, 40, 41,

42, 43, 44, 52, 53, 58, 72, 73, 135genetically predisposed 23, 38genetically prone 19, 31, 43genetically resistant 75, 129genetically resistant hair 75genetic code 41genetic combination 32genetic factor 22, 73genetic factors 21, 42, 44, 53, 72

154


genetic hair loss 32genetic pattern 28genetic predisposition 31, 33, 40, 43genetics 21, 22, 42Germany 61gout medicines 20Great Depression 62GROWTH CYCLE 3, 37growth phase 34, 42, 106, 108, 110,

111growth rate 34

Hhair augmentation 17hair cloning 132, 133, 136hair color 19, 23, 75, 125, 141Hair coloring 27hair condition 23hair cycle 30, 135hair graft units 65hair growth 6, 19, 24, 27, 28, 30, 31,

32, 33, 34, 35, 37, 38, 39, 43, 48, 51, 68, 78, 103, 108, 118, 119, 120, 135

hair growth cycle 33, 37, 38, 39, 51HAIR GROWTH CYCLE 3, 37hair loss condition 48, 56hair loss conditions 20, 54, 56, 72hair loss expert 36hair loss medications 34, 35, 71, 136hair loss patterns 75hair loss treatments 31, 43, 56, 117Hair Multiplication 6, 132hair restoration doctor 16hair restoration procedure 13, 14, 16,

66, 93, 111hair restoration surgeon 60, 72, 94Hair restoration surgeons 63, 113hair restoration surgeries 108, 114Hair restoration surgery 15, 58, 76hair root 3, 18, 38hair’s growth cycle 42hair structure 37

hair systems 124hair thinning 12, 34, 53, 97hair transplant 4, 5, 6, 12, 13, 14, 15,

25, 27, 35, 40, 47, 49, 53, 54, 55, 56, 57, 58, 60, 64, 65, 66, 68, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 81, 82, 84, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 105, 106, 108, 109, 110, 111, 113, 114, 115, 120, 123, 128, 129, 131, 132, 139, 141, 143, 144, 145, 146, 147, 148, 149, 150

hair transplantation 4, 35, 43, 44, 47, 49, 50, 57, 58, 62, 63, 65, 71, 75, 76, 78, 80, 81, 82, 87, 88, 91, 93, 95, 97, 101, 103, 105, 107, 108, 110, 111, 128, 130, 131

hair transplant recipients 14hair transplant surgeon 55, 56, 66,

71, 77, 81, 93, 94, 96, 111hair transplant surgeons 12, 35, 64,

82, 113, 114hair transplant surgery 4, 14, 40, 57,

64, 65, 68, 70, 71, 72, 73, 74, 75, 76, 77, 89, 93, 94, 95, 97, 114, 120, 123

hair units 68, 79, 140Hamilton-Norwood scale 44harvested follicular units 77harvesting 67, 77, 79, 80, 83, 102,

103, 127, 132headpieces 61Heparin 50hereditary 24, 27, 41, 44, 63, 73, 134hereditary alopecia 134hereditary baldness 63hereditary condition 41hereditary genetic factor 73hereditary hair loss 24Hereditary hair loss 32, 42, 43Hereditary-pattern 42heredity 30, 31

INDEX

155

Historians 11Hormonal 19, 44, 52Hormonal and genetic factors 44hormonal change 19hormonal changes 21, 29, 42, 52hormonal evaluations 56hormonal imbalance 60hormonal imbalances 19, 56, 74hormonal levels 53, 56hormonal problems 19, 20hormones 20, 31, 38, 39, 46, 53, 60hypertrophic reaction 115Hypopigmentation 84, 85

Iimmune disorder 59immune system 21implantation 67increase blood fl ow 33infection 50, 59inherit 74Internal Revenue Service 11, 12Iron defi ciency 24, 74Iron panel 56ISHRS 131

Kkeratin 38keratinized protein 11, 12, 18kerontinized fi ber 124

LLab Work 56laser treatments 125Latisse 105, 106Laxometer 6, 33, 128, 129licensed professional 23local anesthesia 103local anesthetics 95local hair loss 48, 59lupus 59, 74, 102

MMacro 55magnifi cation 55, 64, 67, 102male and female pattern hair loss 40male hormone 43, 74, 117male hormones 31, 38, 60male or female 23, 41, 49, 52, 92male pattern baldness 23, 24, 44, 45,

47, 53, 71, 117, 118, 119, 120, 122

male-pattern-baldness 21Male Patterned 52, 53male patterned baldness 12, 13, 14,

29, 33, 41, 42, 44, 58, 76, 118, 120

male patterned hair loss 26, 123male pattern hair loss 55Manual methods 83mechanism 44, 83medical attention 9, 19medical condition 18, 56, 57, 102,

134medical evaluation 19, 73medical hair restoration 40, 61, 119,

134medical problems 54, 74medical professionals 43medical technicians 66Medical treatments 35, 104Medulla 38Mega and giga sessions 128Megasession hair transplants 128memory recall 14menopause 72MERCK 118Micro-evaluation 55microfi bers 124, 125micro-graft 68micro-graft ing 63, 64Microscopic 55, 71, 75, 127microscopic evaluation 29, 35, 52,

57, 59Microscopic evaluation 55, 71, 75

156


microscopic level 75microsurgical hair 64miniaturization 29, 42, 44, 46, 55, 56,

57, 74, 122, 123Miniaturization 3, 52, 55, 56, 75miniaturization process 44Miniaturization study 55, 75miniaturized 44, 46, 52, 122miniaturized hair 46, 122mini-graft 68minoxidil 5, 28, 57, 119, 120, 123,

135Minoxidil 34, 46, 47, 59, 96, 119, 120motorized devices 80, 130, 131Motorized methods 83MPB 3, 40, 41, 42, 43, 44, 45, 46, 52,

53, 54, 55, 71, 72, 73, 76, 124myth 17, 29, 30, 34, 35, 122Myth 29myths 3, 18, 26, 35

NNational Institute of Health 133natural results 4, 16, 65, 68, 103negative eff ects 12, 15negative impact 15negatively impact 16NeoGraft 131Norman Orentreich, MD 62

Oobservation 16Okuda 62oral medication 47outpatient procedure 99

Ppattern 19, 21, 23, 24, 27, 28, 35, 40,

41, 42, 43, 44, 45, 46, 47, 52, 53, 54, 55, 60, 65, 68, 71, 72, 74, 76, 99, 103, 109, 117, 118, 119, 120, 122

pattern baldness 23, 24, 27, 41, 42, 44, 45, 47, 52, 53, 60, 65, 71, 72, 74, 76, 117, 118, 119, 120, 122

patterned alopecia 24patterned baldness 12, 13, 14, 21, 28,

29, 33, 41, 42, 44, 49, 52, 53, 58, 72, 76, 92, 117, 118, 120, 123, 134

patterned hair loss 22, 25, 26, 27, 29, 57, 71, 123, 124, 126, 135

pattern hair loss 40, 46, 55pattern of baldness 28, 71pattern of hair loss 35, 55permanent hair loss 22, 27, 28, 33, 39permanents 23permanent zone 57, 66, 75, 105, 129,

140physical evaluation 55pigmentation 70, 85, 99Platelet Rich Plasma 135poor circulation 29, 30positive impact 15, 139Professor Dom Unger 61progesterone 20, 74progesterone levels 20, 74Prolactin 56Propecia 5, 35, 47, 49, 59, 96, 118,

119, 121, 135, 136, 137Propecia® 34Proscar 118prostaglandin 105protein 11, 18, 38, 65PRP 135psychological disorder 48Psychological Eff ects 3, 13psychological impact 13psychological impacts 11, 12Psychological Impacts 3, 12psychological variables 13psycho-social impact 13psycho-social impacts 11, 12psycho-social problems 15punch graft s 63

INDEX

157

Rradiation therapy 48recipient areas 64, 66, 110recipient dominance 63recipient sites 67, 77, 94remedies 62, 117remedy 17replacement techniques 64Robotic Hair Restoration 83Robotic hair transplant system 131robotic system 132Rogaine 5, 34, 57, 59, 117, 119, 120,

123, 124, 135Rogaine® 34Roman Empire 61

SSAFE System 6, 130, 131satisfaction 13, 57scalp 21, 23, 26, 27, 28, 30, 31, 32,

33, 45, 46, 47, 49, 50, 51, 52, 53, 54, 55, 56, 57, 59, 61, 62, 65, 66, 67, 71, 74, 75, 76, 79, 80, 82, 83, 91, 92, 96, 98, 99, 100, 102, 103, 105, 107, 108, 109, 110, 111, 113, 114, 115, 119, 122, 123, 124, 125, 126, 128, 129, 130, 136, 139, 140, 141

scalp advancement 113scalp circulation 30scalp examination 55scalp infectious diseases 50scalp laxity 32, 75, 129, 130, 141Scalp Micro-Pigmentation 6, 141Scalp-Micro Pigmentation 140scalp pigmentation 99Scalp Reduction 6, 140scalp scars 114, 139scar revision 114, 115, 139, 140, 141Scarring Alopecia 50sebaceous gland 97sebaceous glands 85

sedation 103self-esteem 11, 12self image 9, 139self-image 9, 10, 11, 12, 14, 26, 43,

64, 68, 94, 113sequential strip removal 128sex hormones 20Sexual Dysfunction 5, 121shedding 18, 19, 39, 58Shock Loss 5, 49, 91, 96side eff ect 20, 23, 59, 118, 121side eff ects 20, 49, 55, 94, 118, 121,

122, 136signifi cant 9, 10, 14, 16, 21, 25, 33,

41, 55, 57, 63, 72, 74, 83, 89, 95, 121, 122, 123

skin level surgery 94slivers 78SMP 6, 85, 140, 141social phenomenon 11, 12social status 11stereoscopic microscopes 67Stereotactic Microscope 6, 127Steroids 23, 31, 96Strip Hair Transplant 81strip method 63, 77, 81, 82, 99, 102Strip Method procedure 64strip procedure 83, 105strip technique 79Strip Transplant 81suction 80, 83surgeons 12, 35, 36, 47, 61, 62, 63,

64, 68, 71, 76, 82, 113, 114, 129, 130, 131

symptoms 33, 43synthetic 124

TT3 56T4 56techniques 62, 64, 68, 80, 81, 82, 83,

94, 102, 109, 114, 128, 130, 131, 134, 141

158


technologies 26technology 44, 74, 120, 129, 141telogen 25, 33, 39, 49, 51, 69, 93, 96,

110telogen effl uvium 25, 33, 49, 93, 96Telogen effl uvium 48, 49, 58, 92testosterone 39, 53, 55, 56, 60, 117,

119, 136testosterone levels 53, 55the strip method 63, 77, 82thyroid diseases 102thyroid disorders 74thyroid gland 20Tightness 32, 95tobacco toxins 34Toppik 124toxins 34, 48traction alopecia 22, 27, 30, 49, 104Traction Alopecia 48transaction 67, 127transection 82, 84, 85, 111, 115, 130,

131transplantation 4, 35, 43, 44, 47, 49,

50, 57, 58, 61, 62, 63, 65, 67, 71, 75, 76, 77, 78, 80, 81, 82, 87, 88, 91, 93, 94, 95, 97, 101, 103, 105, 107, 108, 109, 110, 111, 127, 128, 130, 131, 132, 133, 137, 140

transplant surgeon 55, 56, 66, 68, 71, 77, 81, 93, 94, 96, 111

traumatic alopecia 61

treatment 11, 12, 20, 36, 43, 44, 46, 47, 48, 53, 54, 55, 56, 57, 58, 59, 61, 63, 76, 85, 89, 97, 98, 100, 104, 105, 111, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 133, 134, 136, 137

treatments 20, 27, 31, 34, 35, 43, 47, 50, 56, 58, 59, 104, 117, 118, 124, 125, 136, 137

trichophytic closure 98, 115Trichotillomania 48, 59, 102, 104TSH 56turbine alopecia 29

VVitamin A 20vitamin defi ciency 31vitamin or nutritional 33

WWalter Unger 141William Rassman 13World War II 62Wurzburg 61

ZZinc 24zinc defi ciency 24

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